Health inspection·February 4, 2021

F 0568 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to send quarterly personal fund account balance statements to resident's responsible party for 1 of 3 sampled residents reviewed for personal funds, (#2). Findings: Resident #2 was admitted to the facility on [DATE] for long term care. His diagnoses included Alzheimer's disease dementia with behavioral disturbances. A review of the face sheet revealed Medicaid was his payer source. A review of the medical record revealed his most recent comprehensive Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status could not be completed because the resident was never/rarely understood, had both long term and short term memory problems, and had severely impaired cognitive skills for daily decision making. On 2/2/21 at 2:18 PM, a phone interview was conducted with resident #2's designated responsible party and durable Power of Attorney (DPOA). She acknowledged the resident was a Medicaid recipient. She said he had a trust fund with the facility's business office but she had not received statements of his account balance from the facility' business office for the last few years. The address of resident #2's responsible party/POA was documented on the information page in the resident's electronic medical record (EMR). The address in the EMR was confirmed by the responsible party as her correct current address. On 2/3/21 at 5:30 PM, interview with the Business Office Manager (BOM), Assistant Business Office Manager (ABOM), and the Regional Business Office Director (RBOD) acknowledged that resident #2 had Medicaid as his payor source. They acknowledged that he had a personal trust fund account with the facility. They also acknowledged the resident was confused and had a responsible party/financial and medical POA family member. Review of resident #2's business office record revealed the POA paperwork had been signed by the family member and the resident as of 4/21/16. The responsible party/POA had signed a Resident Trust Account Agreement and Beneficiary Form on 11/3/17. The facility directly received the resident's monthly Social Security checks for direct payment. A review of the form read that the responsible party's address was in a different state. Review of resident #2's 2020 quarterly trust fund statements revealed that they had been sent to an address in a different state. The BOM, ABOM, and RBOD acknowledged that they were unaware of the responsible party's address change and the business office electronic system and the medical records electronic system did not automatically synchronize address changes. They said address changes had to be manually input in the business (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 6 Event ID: 106029 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 106029 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Lake Mary 710 North Sun Drive Lake Mary, FL 32746 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)