Inspection·June 18, 2025

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and facility document review, the facility failed to ensure an effective pest control program was in place in three rooms (124 B, 126 B and 204 A/B) out of 11 rooms observed.Findings included:During an observation of room [ROOM NUMBER] B on 6/16/2025 at 08:46 A. M., there were three black live insects on the resident's overbed table near the resident's bed. In an immediate interview, the resident stated ants are always in her room, and that they never leave. She states she complains to the staff daily about issues including ants. She states she has seen big bugs in the facility as well. During a tour of room [ROOM NUMBER] on 06/17/2025 at 11:04 A. M., an observation of the bathroom revealed a live brown colored insect crawling on the wall under the sink, in the bottom right corner near where the floor tile meets the wall. In an interview with the resident explained there were insects in the facility and stated a roach was seen earlier crawling across the wardrobe header. The resident stated it went down to the side of the wardrobe cabinet and to the right on the floor. On 06/17/2025 at 11:07 A. M., an interview was conducted with Staff D, Licensed Practical Nurse (LPN)/Unit Manager. She stated that she had not seen any insects, but the residents had complained to her about ants. During an interview on 06/17/2025 at 11:11 A. M., with a random resident, he stated he saw flies on 06/16/2025. He stated that he didn't tell staff because it was a waste of time. During an interview with a random resident on 06/17/2025 at 02:03 P. M., he stated he saw a bug in the 100 hallway near room [ROOM NUMBER]. He stated he sighted it a week prior. The resident stated he notified staff, and the staff proceeded to smash the bug, by stomping on it.An observation of room [ROOM NUMBER] Bed B on 06/18/2025 at 08:07 A. M., revealed the room had a food tray with two small live insects on the table near the resident's bed. The resident confirmed that this was their breakfast tray. Observations of a cubby counter space in between the wardrobe section of the room showed a food tray. The observations revealed ants were on the tray with a tea bag and other items. There was a food plate from the prior day's dinner with no food on it. The plate had approximately forty to fifty live small insects crawling over the plate. An interview was conducted on 06/18/2025 at 08:09 A. M., with Staff C, Registered Nurse (RN)/UM, in 126 B. Staff C UM RN confirmed she saw the live ants on the overbed table and the wardrobe cubby. She stated that she would speak with maintenance. During a tour on 06/18/2025 at 08:22 A. M., observations of room [ROOM NUMBER] B revealed approximately five live small crawling insects, on a counter in a cubby in the wardrobe section connected to the wall near the window. The resident had items on the counter, including a plastic bag that the ants were crawling on. An interview on 06/18/2025 at 08:21 A. M., with Resident #16, he stated that ants are all over the room, on the floor, under the AC, and in the bathroom. He said that it was a waste of time to inform staff. On 06/18/2025 the nursing home administrator (NHA) provided the facility's Service Agreement for Commercial Pest Management, which revealed the facility has a signed service agreement with a pest control maintenance company. The service agreement was signed and dated 04/11/2024. The Residents Affected - Few (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 2 Event ID: 106116 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 106116 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Bryan Dairy 9035 Bryan Dairy Rd Largo, FL 33777 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)