Health inspection·October 26, 2023

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an individualized activity program based on preferences and plan of care was provided for 1 of 2 dependent residents reviewed for Activities, of a total sample of 44 residents, (#73). Residents Affected - Few Findings: Resident #73 was admitted to the facility on [DATE], with her most recent readmission on [DATE]. Her diagnoses included Alzheimer's disease, generalized muscle weakness, symptoms and anxiety disorder. Review of the significant change Minimum Data Set (MDS) assessment, with Assessment Reference Date of 9/18/23, revealed the resident was rarely/never understood. The assessment noted daily and activity preferences indicated the resident liked listening to music, doing things with groups of people, and participating in favorite activities. Review of the Psychosocial Evaluation conducted on 4/01/22, revealed the resident preferred one on one, and small group activities. Her current interest included animals/pet, music, and television on Spanish channels. Documentation read, will receive 1:1 visits as tolerated. She enjoys watching Spanish TV channels, nail spa, listen to Spanish music, and hand massage. Observations on 10/23/23 at 11:24 AM, at 12:40 PM, at 3:49 PM, and on 10/25/23 at 10:15 AM, resident #73 was lying in bed on her back. She did not respond when spoken to, and no form of activities was noted. The television was not on, and no music was being played. On 10/25/23 at 10:22 AM, the Director of Activities stated that bird therapy, and room visits were provided by the Activity Department for dependent residents. He stated resident #73 did not do much but liked to listen to music. The Director of Activities stated the Activities Assistant documented on the Activity Log when room visits were made. Review of the Activity log for the period 9/15/23 to current revealed no documentation to indicate room visits or any form of activities were provided for resident #73. This was confirmed by the Director of Activities. On 10/25/23 at 10:30 AM, the Activities Assistant stated that in the morning, she went room to room, provided ice, and friendly visits to residents, and documented the interaction on the activity log. She stated she had done room visits with resident #73 but forgot to document the visits in the Activity Log. On 10/25/23 at 10:43 AM, Certified Nursing Assistant (CNA) B, stated resident #73 required total (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 4 Event ID: 106074 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 106074 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Kissimmee Gardens 1120 W Donegan Ave Kissimmee, FL 34741 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)