Health inspection·June 3, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Inserted Central Catheter (PICC) inserted in the right upper arm, and a left leg surgical site. The staff noted the resident arrived at the facility on 4/23/25 at approximately 5:50 p.m., was A&O x4, a wound vac noted to right leg with a cast in place, per order cast is not to be removed until f/u (follow up) with surgeon, and a PICC in right upper arm. The evaluation did not describe the drainage in the wound vac tubing or canister, or the amount seen. Residents Affected - Few Review of a late entry Physician Progress Note, effective 4/24/25 at 10:37 p.m. revealed Resident #1 had been admitted at the Skilled Nursing Facility (SNF) after hospitalization for right knee issues. The history showed the resident had underwent a second-stage revision of the right total knee arthroplasty which included the removal of an antibiotic spacer, application of a wound VAC, and insertion of antibiotic beads. The resident was weight-bearing as tolerated, wound VAC was to remain in place for 2 weeks and due to deconditioning and need for long-term antibiotics the resident had been admitted for further rehabilitation. The plan was for the resident to continue current antibiotic regimen, follow up with Orthopedics in 2 weeks, and to Maintain wound VAC for 2 weeks. Review of Resident #1's skilled notes dated 4/24, 4/25, 4/26, 4/28, and 4/30/25 revealed staff did not comment on the presence of the wound vac or if the resident had a surgical incision. The notes showed the vascular access was not present on 4/24, 4/25, and 4/28 but was present on 4/26 and 4/30/25. The record revealed staff did not document a skilled note on 4/27 or 4/29/25. An interview was conducted on 5/20/25 at 12:32 p.m. with Staff A, Licensed Practical Nurse/Unit Manager (LPN/UM). The staff member reported Resident #1 was admitted with a wound, believed it was either a pressure or surgical wound, had a wound vac which the resident was admitted with, and an immobilizer which kept leg straight. Staff A stated a wound vac dressing was to be changed on Monday-Wednesday-Friday and if the wound vac was inoperable staff were to apply a wet-to-dry dressing, contact the surgeon. The staff member stated the wound vac and wet-to-dry dressing orders were standard. Staff A stated the resident came in close to the weekend, on Wednesday 4/23/25. The staff member reported working Monday through Friday and was notified by the Nurse Practitioner the following Monday the resident's wound vac was not working and stated need to reach out to the surgical team. Staff A stated the weekend supervisor had initiated the wet-to-dry dressing on Sunday (4/27/25). Staff A stated the expectation for staff was to write a note describing the drainage and the amount, pain or discomfort, and if it had a foul smell. Staff A said, All that goes into your progress note. The staff member reviewed the April 2025 MAR and TAR confirming it did not include information related to the amount of drainage. The wound vac was to be on for 2 weeks and the vac would have been set to run for 2 weeks. Staff A did not know the preset, and the assumption was it stopped working due to the preset. Staff A reported directing the floor nurse to apply the wet-to-dry dressing, once a day. The original wet-to-dry dressing was done on 4/26 at 10:19 a.m. Staff A, LPN reviewing the record stated the dressing was also done on 4/27 at 11:16 a.m., and on 4/28 before the resident left. Staff A confirmed there was no documentation related to the application of the dressing on 4/25/25. An interview was conducted on 5/20/25 at 2:05 p.m. with the Nursing Home Administrator (NHA) and the Director of Nursing (DON). The NHA reported Resident #1 had been admitted on [DATE] with a wound vac to the post-surgical wound on right knee. The facility was notified by the surgeon's office (4/30/25) that Resident #1's wound was not progressing, and they suggested the resident be transferred to hospital for evaluation. The NHA clarified the surgeon's office had notified the facility the resident was going to the hospital from the appointment. The NHA reported the following staff interviews: - Staff B, the resident's primary nurse on (Sunday) 4/27/25, had identified the wound vac cord was not providing power to the device and had notified the weekend supervisor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 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 105951 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oakfield 1465 Oakfield Dr 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few - Staff C, Registered Nurse (RN) was the evening nurse on 4/26 and had stated the wound vac was plugged in and very little drainage was in tubing and canister. - Staff D, Registered Nurse/Weekend Supervisor (RN/WS) reported being made aware on 4/27 the wound vac cord was not providing power and had looked in central supply (CS) for another cord before reaching out to the CS coordinator. - Staff E, Central Supply (CS) Coordinator confirmed Staff D had reached out for an alternative cord and the coordinator had attempted placement of another cord which was not compatible. - Staff A had been notified by the Nurse Practitioner (NP) on 4/28/25 that Resident #1's wound vac was not functioning. Staff A had contacted the surgeon's wound care office and had initiated a wet-to-dry dressing change. - Staff F, RN was the assigned nurse (for Resident #1) for the 4/28-day shift reported . the wound vac was not powered on, and the area did not have any edema or redness. - Staff G, RN was the assigned nurse on 4/29 and had reported not being aware of any concerns with the wound vac. - Staff H, Certified Nursing Assistant (CNA) . reported the machine was not turning on. During the on-going interview, The NHA reported an order was placed on 4/28 with a start date on 4/29 for a wet-to-dry dressing. The DON stated if a wound vac was not working staff were to get hold of surgeon and get orders. The DON was unaware of the surgeon's on-call. The NHA reported reviewing the TAR which had shown on 4/29 the wet-to-dry dressing was not applied. The NHA stated the primary nurse had notified the weekend supervisor of non-functioning wound vac. The primary nurse should know to call the physician. The staff members stated education had been provided to nurses that if a wound vac enters the facility or was applied, they have an order to notify physician to obtain a wet-to-dry dressing and to check vac functioning and placement every shift. The DON stated the expectation was for the wound to be assessed and documented in the daily skilled charting. The DON confirmed the resident did have a PICC and staff should be documenting the existence, location, and any signs or symptoms of infection. The DON stated the expectation was for staff to document if the wound vac was functioning, location, description of drainage and the amount if able to see it. Review of Resident #1's progress notes revealed a late entry note, effective 4/28/25 at 5:28 p.m., created on 4/30/25 at 11:32 a.m., written by Staff A showing the writer had received a call from the Orthopedic office with orders to place a wet to dry dressing on the patient's wound and they would like to see the resident on 4/30 instead of next month, the writer placed new orders in the electronic record and the facility would continue with the plan of care at this time. Review of Resident #1's April 2025 Treatment Administration Record (TAR) revealed the following order: - Treatment as follows: Cleanse left knee with wound cleanser and pat dry. Apply saline gauze to wound bed and cover with abdominal (abd) pad every day and as needed for soiling or dislodgement every day shift for wound care. Start date 4/29/25 at 7:00 a.m., held from 4/30 12:44 p.m. to 5/1 at 12:00 a.m., and discontinued on 5/2/25 at 12:28 p.m. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 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 105951 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Oakfield 1465 Oakfield Dr 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The April 2025 TAR revealed the dressing had been applied on 4/29/25. The corresponding as needed (prn) order revealed the dressing had not been applied on 4/28, 4/29, or 4/30/25. An interview was conducted on 5/21/25 at 1:37 p.m. with Staff D, RN/WS (Weekend Supervisor). The staff member reported being notified on Sunday (4/27/25) morning that the wound vac was not working and had sent a message to CS that the battery was not charging. Staff D stated the primary nurse would have been the one to contact the physician and the policy was if a wound vac was not working, the expectation was to keep the dressing clean, dry, and intact. Staff D stated not knowing what Resident #1's orders were, and the policy was to have either wet-to-dry (dressing) or to keep the wound vac's sponges clean, dry, and intact, whatever the order says. A request was made on 5/20/25 for policies regarding nursing documentation and for wound vac care/maintenance. The facility showed they did not have those policies. Review of the policy - Abuse, Neglect, Exploitation, & Misappropriation, revised 11/16/22, revealed 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. Employees of the center are charged with a continuing obligation to treat residents, so they are free from abuse, neglect, mistreatment, and/ or misappropriation of property. No employee may at any time commit an act of physical, psychological, or emotional abuse, neglect, mistreatment, and/ or misappropriation of property against any resident. Violation of the standard subject employees to disciplinary action, including dismissal, provided herein. The policy defined neglect as: the failure of the center, its employees or service providers provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Examples include but are not limited to: - Failure to take precautionary measures to protect the health and safety of the resident. - Intentional lack of attention to physical needs including, but not limited to, toileting and bathing. - Failure to provide services that result in harm to the resident, such as not turning a bed fast resident or leaving a resident in a soiled bed. Review of the policy - Daily Skilled Nursing Progress Note, revised 9/29/17, revealed Residents receiving skilled care have progress documented daily in the medical record by the nurse. The procedure included: - Use the daily skilled note to document resident's progress daily on skilled care. - May document a narrative note in the additional note section for any items not addressed in the note. - Incidental or by exception documentation may also be included in the narrative note. -Sign, save and lock assessment in electronic record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105951 If continuation sheet Page 4 of 4