Health inspection·March 20, 2025

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on record review, staff interview, and policy review, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN, CMS-10055 form) to 1 of 3 sampled residents reviewed for beneficiary notices. The SNF ABN provides information to beneficiaries so they can decide if they wish to continue receiving the skilled services that may not be paid for by Medicare and assume financial responsibility. (Resident #64) Residents Affected - Few The findings include: Based upon facility documentation, Resident #64 was discharged from a Medicare Part A stay on 2/24/25 and remained in the facility. Review of the Beneficiary Notification review form (CMS 20052) completed by the Business Office Manager (BOM) on 3/18/25 revealed the facility initiated the discharge of Resident #64 from Medicare Part A services when benefit days were not exhausted. The form indicated the SNF ABN (CMS 10055) was not provided to the resident because the resident was not picked up under skilled Medicare Part B services. An interview was conducted with the Administrator on 3/18/25 at 1:11 PM. The Administrator confirmed the notice (SNF ABN) was not served to the resident and agreed if the resident was discharged from Part A and remained in the facility, the resident should have received the SNF ABN notice. Review of the facility policy for SNF Advance Beneficiary Notification (ABN) & Notice of Medicare Provider Non-Coverage (BO-510 revised 5/1/18) revealed that the SNF Advance Beneficiary Notification (SNF ABN) & the Notice of Non-Coverage will be used to properly notify a Medicare Part A resident and/or responsible party of the clinical team decision that the resident, no longer meets the Medicare criteria for daily skilled services. SNF's must provide the Notice of Medicare Provider Non-Coverage and the SNF ABN to Medicare beneficiaries no later than two days before the effective date of the end of the coverage that their Medicare coverage will be ending. Page 1 of 3 105148 105148 03/20/2025 Aviata at Emerald Shores 626 N Tyndall Pkwy Callaway, FL 32404

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observations, record review, staff interview, and policy review, the facility failed to provide appropriate fingernail care to 1 of 1 sampled residents reviewed for activities of daily living. (Resident #33) Residents Affected - Few The findings include: Observations of Resident #33 were conducted on 3/17/25 at 11:54 AM, 3/18/25 at 11:31 AM, and 3/19/25 at 9:05 AM. During the observations, the resident's left hand was observed to be contracted and 4 of the 5 fingernails (all nails except the thumb nail) on her left hand were long and untrimmed. Further observation of Resident #33's left hand was conducted on 3/19/25 at 10:45 AM with the Director of Nursing (DON). The DON observed the nails on the resident's left hand and confirmed the resident's left hand was contracted. The DON measured the longest nail on the resident's left hand and stated it was 1 cm past the nail bed. The DON confirmed this was not an acceptable length and the resident's nails should be cut short. The DON then spoke with a certified nursing assistant (CNA) and stated the CNA reported she had attempted to trim the resident's fingernails, but they were too thick. The DON confirmed the CNA should have reported this to the nurse or manager. A review of Resident #33's record revealed a significant change minimum data set (MDS) with an assessment reference date of 1/17/25 indicating the resident was dependent for personal hygiene. A review of the last 20 days of progress notes revealed no documented refusals of nail care. Review of the task menu revealed her last documented bath or shower was performed on 3/17/25. A review of the current care plan dated 11/12/24 for Alteration in Usual Functional Performance in self-care related to activity intolerance, fatigue, impaired balance, and limited mobility revealed the resident was dependent for personal hygiene. Review of the facility policy for Bathing/Showering (N-1130 revised 9/1/17) revealed that staff should trim the resident's fingernails during bathing. 105148 Page 2 of 3 105148 03/20/2025 Aviata at Emerald Shores 626 N Tyndall Pkwy Callaway, FL 32404

F 0693 Level of Harm - Minimal harm or potential for actual harm Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based upon observations, interviews and record reviews, the facility failed to provide proper enteral feedings for 2 of 2 residents observed for enteral feeding. (Resident #1 and #44) Residents Affected - Few The findings include: On 03/17/25 at 11:52 AM, Resident #1 was lying in bed with Glucerna being administered at 55 ml/hr. However, Resident #44's name was written on the tube feeding bottle. Resident #44 was being administered Jevity 1.5 at 45ml/hr but the bottle had Resident #1's name written on the tube feeding bottle. (photographic evidence obtained) As this was observed, Certified Nursing Assistant (CNA) B came into the room. She was asked to identify Resident #1 and #44. The CNA stated Resident #44 was in the B-bed and Resident #1 was in A-bed. The CNA went to get the nurse to assist further with tube feeing concerns An interview with Staff Member A, a Licensed Practical Nurse (LPN) was conducted on 3/17/25 at 12:05 PM. Nurse A was alerted to the switched tube feeding bottles. Staff Member A confirmed that Resident #1's tube feeding was not correct. Resident #1 should have Jevity infusing instead but had Glucerna infusing. Staff Member A confirmed that the tube feeding on Resident #44 was the wrong tube feeding, Resident #44 should have Glucerna infusing not Jevity. A record review on 3/17/25 at 12:30 PM revealed that Resident #1 has a diagnosis of a Cerebrovascular accident (CVA) with hemiplegia affecting the left dominant side, profound intellectual disabilities, Cerebral Palsy, Dysphagia, and Aphasia. The physician's orders states that he is to have Enteral feeding of Jevity 1.5 at 55 ml/hr for 20 hours, off at 10:00 AM, On at 2:00 PM with H20 flush at 55 ml/hr for 20 hours, off at 01:00 AM on at 02:00 AM. an A record review of Resident #44 on 3/17/25 at 12:40 PM revealed that Resident #44 has a diagnosis of cognitive communication deficit, dysphagia following CVA, Type two diabetes, and unspecified severe protein malnutrition. Physician orders state that Resident #44 had an order for Enteral Feed Glucerna 1.5 at 45 ml/hr two times a day with 80 ml/hr flush for 20 hours. On 3/17/25 at 1:00 pm, Resident #1 and Resident #44's tube feedings have been removed from the residents' room at this time. On 3/17/25 at 02:00 PM, facility policy for enteral feeding-enteral nutrition (with effective date of 11/30/2018) states that the nurse administers enteral feeding when volume control is indicated and as ordered by physician; procedure is obtain physician order and identify resident. 105148 Page 3 of 3