Health inspection·February 1, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, interview, and the facility policy and procedure review, the facility failed to provide a safe, clean, comfortable, and homelike environment in 1 of 4 residential halls (Photographic evidence obtained). Findings include: During an observation on 1/29/2024 at 10:55 AM, there were two vinyl tiles that were lifted at the corner in the center of the B Wing Hall floor. During an observation on 1/30/2024 at 12:35 PM, there were two vinyl tiles that were lifted at the corner in the center of the B Wing Hall floor. During an interview on 1/30/2024 at 12:42 PM, the Maintenance Director stated, I started working here in November of last year [2023] and the tiles were lifted. I know they are lifted and have the tiles to replace them in the shed but have not gotten to it yet. I am the only one here. I do not have a work order for the repair. I know I need to fix them. Review of the facility policy and procedure titled Maintenance with the last review date of 2/1/2024 showed the policy read, Policy: The facility's physical plant and equipment will be maintained through a program of preventive maintenance and prompt action to identify areas/items in need of repair. Procedure . The Director of Environment Services will perform daily rounds of the building to ensure the plant is free of hazards and in proper physical condition. Page 1 of 11 105413 105413 02/01/2024 Aviata at Brooksville 1445 Howell Ave Brooksville, FL 34601

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the minimum data set assessment was accurate for 1 of 4 residents reviewed for mood and behavior, Resident #71. Residents Affected - Few Findings include: Review of Resident #71's admission record showed the resident was admitted to the facility on [DATE] with the diagnoses including dementia, major depressive disorder, schizophrenia and brief psychotic disorder. Review of Resident #71's hospital Discharge summary dated [DATE] showed the summary read, Hospital Course: [Resident #71' name] is a 88 y.o [year old] male with past history of diabetes, hyperlipidemia, dementia, Alzheimer's, schizophrenia presented to the emergency room after a fall at his SNF [skilled nursing facility] . Review of Resident #71's Preadmission Screening and Resident Review (PASRR), dated 10/26/2023, revealed diagnosis of schizophrenia checked as a mental illness. Review of Resident #71's psychiatric visit notes, dated 11/10/2023, showed the diagnoses of major depressive disorder, unspecified dementia, brief psychotic disorder, and other specified persistent mood disorders. Review of Resident #71's admission Minimum Data Set (MDS), dated [DATE], did not reveal diagnoses of schizophrenia or psychotic disorder in Section I- Active Diagnoses. During an interview on 1/31/2024 at 1:30 PM, the Director of MDS stated, He [Resident #71] does have those diagnoses. It [the minimum data set assessment] needs to be corrected. Review of the facility policy and procedure titled MDS with the last review date of 2/1/2024, showed the policy read, Policy: The center conducts initial and periodic standardized, comprehensive and reproducible assessments no less than every three months for each resident including, but not limited to, the collection of data regarding functional status, strengths, weaknesses, and preferences using the federal and/or state required RAI [Resident Assessment Instrument]. Procedure . Each person completing a section or portion of a section of the MDS signs the Attestation Statement indicating its accuracy. 105413 Page 2 of 11 105413 02/01/2024 Aviata at Brooksville 1445 Howell Ave Brooksville, FL 34601

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition were referred for level II Preadmission Screening and Resident Review (PASRR) for 2 of 4 reviewed residents, Residents #42 and #53. Findings include: 1. Review of Resident #42's admission record revealed the resident was admitted on [DATE] and had a diagnosis of bipolar disorder with onset date of 7/21/2023. Review of Resident #42's level I PASSR completed on 11/28/2023 revealed no diagnosis of bipolar disease listed and indicated that level II PASRR was not required. Review of Resident #42's care plan, dated 4/12/2023, revealed the resident had a mood problem related to depression, bipolar disorder, and anxiety. Review of Resident #42's psychiatric service note, dated 8/18/2023, revealed the resident was an unstable [AGE] year-old female that required an assessment related to symptoms of bipolar disorder. During an interview on 1/31/2024 at 11:25 AM, the Director of Nursing (DON) stated that level II screening should have been completed with the new diagnosis for Resident #42 and it was not. 2. Review of Resident #53's admission record revealed the resident was most recently admitted on [DATE] and had a diagnosis of bipolar disorder with onset date of 1/10/2022. Review of Resident #53's level I PASSR completed on 12/28/2022 revealed no diagnosis of bipolar disease listed and indicated that level II PASRR was not required. Review of Resident #53's care plan, dated 4/4/2022, revealed the resident had a mood problem related to bipolar disorder, schizoaffective disorder, and depression. Review of Resident #53's psychiatric services note, dated 9/2/2022, revealed the resident was a [AGE] year-old male with schizoaffective disorder, bipolar type, and psychosis with a history of depression. During an interview on 1/31/2024 at 11:15 AM, the Director of Nursing (DON) stated level II screening should have been completed with the new diagnosis for Resident #53. Review of the facility policy and procedure titled Preadmission Screening and Resident Review (PASRR) with the last review date of 2/1/2024 showed the policy read, Policy: The center will assure that all Serious Mentally Ill (SMI) and Intellectually Disabled (ID) residents receive appropriate pre-admission screenings according to Federal/State guidelines. The purpose is to ensure that the residents with SMI or are ID receive the care and services they need in the most appropriate setting. Procedure: 1. It is the responsibility of the center to asses and assure that the appropriate preadmission screenings, either Level I or Level II, are conducted and results obtained prior to admission and placed in the appropriate section of the resident's medical record . 4. If it is learned after 105413 Page 3 of 11 105413 02/01/2024 Aviata at Brooksville 1445 Howell Ave Brooksville, FL 34601

F 0644 admission that a PASRR Level II screening is indicated, it will be the responsibility of Social Services to coordinate and/or inform the appropriate agency to conduct the screening and obtain the results. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 105413 Page 4 of 11 105413 02/01/2024 Aviata at Brooksville 1445 Howell Ave Brooksville, FL 34601

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 2 residents reviewed for intravenous therapy, Resident #364. Residents Affected - Few Findings include: During an observation on 1/29/2024 at 9:06 AM, Resident #364 was lying in bed, with a clear dressing covering the intravenous therapy site on her right arm. The dressing was dated 1/20/2024. The dressing was observed to be peeling at the edges (Photographic evidence obtained). Review of Resident #364's admission record revealed the resident was admitted on [DATE] with the diagnoses including encephalopathy, perforation of esophagus, acute duodenal ulcer with perforation, malignant neoplasm of colon, essential hypertension, atherosclerotic heart disease of native coronary artery without angina pectoris, and Stage 3 pressure ulcer of sacral region. Review of Resident #364's physician order dated 1/29/2024 read, Vancomycin HCl Intravenous Solution. Use 750 mg intravenously in the morning for infection. Review of Resident #364's physician order dated 1/29/2024 showed the order read, Change dressing on admission or 24 hours after insertion and weekly thereafter and PRN [as needed]. One time only for 1 day change dressing on admission or 24 hours after and as needed change dressing as needed and one time a day every Mon [Monday]. Change dressing weekly. During an interview on 1/31/2024 at 10:32 AM, the Director of Nursing stated, My expectation is that the dressing should have been changed within 24 hours after her [Resident #364] admission. [Resident #364's name] was admitted on [DATE] and it [the dressing] was not changed. Review of the facility policy and procedures titled Guidelines for Preventing Intravenous Catheter-Related Infections last reviewed on 2/1/2024 showed the policy read, Catheter Site Dressing Regimens: 1. Change initial dressing after catheter placement within 24 hours. 105413 Page 5 of 11 105413 02/01/2024 Aviata at Brooksville 1445 Howell Ave Brooksville, FL 34601

F 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 residents received respiratory treatment (oxygen) as ordered by the physician for 1 of 2 reviewed residents, Resident #44. Residents Affected - Few Findings include: Review of Resident #44's admission record revealed the resident was initially admitted on [DATE] with the diagnoses that included a history of pneumonia, acute pulmonary edema, pulmonary fibrosis, respiratory failure, pleural effusion and chronic obstructive pulmonary disease. Review of Resident #44's physician order dated 12/13/2023 showed the resident needed to receive oxygen continuously at 2 liters per minute via nasal cannula. Review of Resident #44's care plan dated 9/25/2023 revealed the resident had oxygen therapy related to congestive heart failure, history of respiratory failure and chronic obstructive pulmonary disease, with the interventions that included giving medications and respiratory treatments as ordered by the physician and oxygen settings as ordered. During an observation on 1/29/2024 at 9:37 AM, Resident #44 was in her room seated on the side of her bed, receiving oxygen via nasal cannula from an oxygen concentrator. Resident #44's oxygen concentrator was set to run at 1.5 liters per minute. During an interview on 1/29/2024 at 9:37 AM, Resident #44 stated she thought her oxygen should be running at 2 liters per minute or at 3 liters per minute, and she did not and could not adjust the oxygen concentrator dial due to the location of the oxygen concentrator. During an observation on 1/30/2024 at 8:42 AM, Resident #44 was in her room seated on the side of her bed, receiving oxygen via nasal cannula from an oxygen concentrator. Resident #44's oxygen concentrator was set to run at 1.5 liters per minute. During an observation on 1/31/2024 at 9:20 AM, Staff A, Licensed Practical Nurse, adjusted Resident #44's oxygen concentrator dial to run at 1.5 liters per minute. During an interview on 1/31/2024 at 9:20 AM, Staff A, Licensed Practical Nurse, confirmed Resident #44's oxygen concentrator was set to run at 1.5 liters per minute. Staff A stated Resident #44's oxygen concentrator should be set at 2 liters per minute. 105413 Page 6 of 11 105413 02/01/2024 Aviata at Brooksville 1445 Howell Ave Brooksville, FL 34601

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles in 4 of 6 medication carts. Findings include: During an observation of A Hall Front Cart on [DATE] at 9:00 AM with Staff B, Licensed Practical Nurse (LPN), there were one opened Aspart insulin pen with no opened or expiration dates, one opened Lantus insulin vial with no opened or expiration dates, two opened Humalog insulin pens with no opened or expiration dates, two opened Glargine insulin vials with no opened or expiration dates, one opened Fluticasone Propionate/Salmeterol Diskus inhaler with no opened or expiration dates, two containers of Prednisolone eye drops with no opened or expiration dates, one container of Ciprofloxacin eye drops with no opened or expiration dates, and one opened container of Latanoprost eye drops with no opened or expiration dates. During an interview on [DATE] at 9:05 AM, Staff B, LPN, stated, Medication should be dated with an opened and expiration date. During an observation of A Hall Back Cart on [DATE] at 9:11 AM with Staff C, LPN, there were one expired Ketorolac Tromethamine ophthalmic drops container with an opened date of [DATE], one opened Breo Ellipta inhaler with no opened or expiration dates, and one opened Wixela inhaler with no opened or expiration dates. During an interview on [DATE] at 9:16 AM, Staff C, LPN, stated, Medications should be dated when opened, and expired medication should be removed from medication cart. During an observation of B Hall Front Cart on [DATE] at 9:23 AM with Staff D, LPN, there were one unopened Humalog insulin pen with a pink sticker to refrigerate, one opened Prostat with no opened or expiration dates, one expired Wixela inhaler with an expiration date of 1/9, and one opened Breo Ellipta with no opened or expiration dates. During an interview on [DATE] at 9:25 AM, Staff D, LPN, stated, The insulin pen will not be used this morning maybe in the afternoon. It should be stored in the refrigerator until it is ready to use. Medication, when opened, should be labeled with opened date. If medication is expired, it should be removed from the medication cart. During an observation of B Hall Back Cart on [DATE] at 9:29 AM with Staff E, LPN, there were one opened Trelegy Ellipta inhaler with no opened or expiration dates, one opened Humalog insulin pen with no opened or expiration dates, and one unopened Lantus insulin vial with a pink sticker to refrigerate. During an interview on [DATE] at 9:35 AM, Staff E, LPN, stated, Medication should be dated when opened with an opened date and insulin should be refrigerated until ready to use. The Lantus will not be used until night time. 105413 Page 7 of 11 105413 02/01/2024 Aviata at Brooksville 1445 Howell Ave Brooksville, FL 34601

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on [DATE] at 10:05 AM, the Director of Nursing stated, Medication should be labeled with the opened and expiration date. If the medication is expired, it should be disposed of accordingly and removed from the medication cart. Insulin that is not open and is not going to be used right away should be stored in the refrigerator. Review of the facility policy and procedures titled Medication Storage last reviewed on [DATE] showed the policy read, Policy: Medications will be stored in a manner that maintains the integrity of the product and ensures the safety of the residents and is in accordance with FL [Florida] Department of Health guidelines. Procedure . F. Expired, discontinued and/or contaminated medications will be removed from the medication storage areas and disposed of in accordance with facility policy. G. Medications will be stored at the appropriate temperature in accordance with the pharmacy and/or manufacturer labeling . H. Medication requiring refrigeration will be stored in a refrigerator that is maintained between 2-8 degrees Celsius (36 to 46 degrees F). Review of the facility policy and procedures titled Insulin Pen Labeling & Packaging last reviewed on [DATE] showed the policy read, Procedure . 2. Insulin Pens are placed in a resealable bag with the following labels/stickers . b. Refrigerate until opened sticker and d. A yellow Date/Expiration sticker. 105413 Page 8 of 11 105413 02/01/2024 Aviata at Brooksville 1445 Howell Ave Brooksville, FL 34601

F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide laboratory services to meet the needs of 1 of 6 reviewed residents, Resident #33. Residents Affected - Few Findings include: Review of Resident #33's medical record revealed the resident was originally admitted on [DATE] with the diagnoses including but not limited to atherosclerotic heart disease of native coronary artery, immunodeficiency due to conditions classified, type 2 diabetes, hyperlipidemia, mood disorder, and major depressive disorder. Review of Resident #33's physician order dated 9/9/2022 showed the order read, Lipids every 6 months every night shift every 6 months starting on the 9th for 1 day(s) related to Hyperlipidemia. Review of Resident #33's physician order dated 9/9/2022 showed the order for CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel), HGB (Hemoglobin) A1C and VPA (Valproic Acid) every night shift every 3 months starting on the 9th for 1 day related to essential hypertension, type 2 diabetes mellitus without complications and mood disorder due to known physiological condition with mixed features. Review of Resident #33's medical record revealed no lipid lab had been completed as ordered by the physician. Review of Resident #33's medical record revealed no labs for CBC, CMP, HGB A1C, and Valproic Acid for December 2022, March 2023, and September 2023. During an interview on 1/31/2024 at 11:00 AM, Staff A, Licensed Practical Nurse, stated, We are unable to locate the other labs. During an interview on 1/31/2024 at 11:10 AM, the Advance Practice Registered Nurse #2 stated, Due to certain medications [Resident #33's name] is taking, he should have labs done more frequently; I would say every 3 months. During an interview on 2/1/2024 at 8:36 AM, the Director of Nursing stated, Staff should be following orders and the labs should have been done. Review of the facility policy and procedures titled Laboratory, Diagnostic and X-Ray with the last review date of 2/1/2024 showed the policy read, Procedure: Schedule laboratory work, diagnostic test and or x-ray as indicated. 105413 Page 9 of 11 105413 02/01/2024 Aviata at Brooksville 1445 Howell Ave Brooksville, FL 34601

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure food was properly and safely stored, covered, labeled, or dated in the area of the kitchen coolers and refrigerators. Residents Affected - Some Findings include: During an observation on 1/29/2024 at 9:00 AM, at the time of walk-through of the dietary department with the Certified Dietary Manager (CDM), the CDM and the Male Dietary Aide had beard or mustache with no covering. In the reach-in cooler, there was a 5-gallon container without an identifying label or date, and a large stainless steel bowl with a yellow pudding type substance with no covering, label or date. The microwave had a buildup of food debris and splatters on the door and the inside top of the microwave. During an interview on 1/29/2024 at 9:10 AM, the Certified Dietary Manager (CDM) stated the 5-gallon container was iced tea and should have had a label and date, and the large stainless steel bowl was pudding made for nursing staff to pass meds and should have been covered, labelled, and dated. The CDM stated that the microwave should have been cleaned the night before and was left dirty. The CDM stated that he and the Male Dietary Aide should follow the policy for all hair covering. During an observation of the kitchen with the CDM on 1/30/2024 at 7:33 AM, there were 14 glasses of a juice type drink in the reach-in cooler with no identifying label or date and 4 clear swirl cups with a fruit type dessert with no cover, date or identifying label. The microwave had numerous areas of rust inside on the sides, top and base. There was a dented can of light tuna on a shelf in the stock room along with approximately 46 cans of assorted foods with no dates that had been removed from the original container. During an interview on 1/30/2024 at 7:38 AM, the CDM confirmed that the observed food products did not have a label and identified them as orange juice that should have been labeled and dated and a leftover fruit dessert from the previous evening that should have been covered, dated and labeled according to the policy. Review of the facility policy and procedures titled Labeling and Dating Inservice last reviewed on 2/1/2024 showed the policy read, Guidelines for Labeling and Dating: All foods should be dated upon receipt before being stored . Leftovers must be labeled and dated with the date they are prepared and the use by date. Review of the policy and procedures titled Receiving last reviewed on 2/1/2024 showed the policy read, Procedures . 4. All canned goods will be appropriately inspected for dents, rust, or bulges. Damaged cans will be segregated and clearly identified for return to vendor or disposal, as appropriate. Review of the facility policy and procedures titled Staff Attire last reviewed on 2/1/2024 showed the policy read, Procedures: 1. All staff members will have their hair off the shoulders, confirmed in a hair net or cap, and facial hair properly restrained. 105413 Page 10 of 11 105413 02/01/2024 Aviata at Brooksville 1445 Howell Ave Brooksville, FL 34601

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to ensure the quality assurance and assurance committee consisted of the required members in 3 of 4 quarters during 2023. Residents Affected - Many Findings include: Review of the QAPI (Quality Assurance Performance Improvement) agenda attendance rosters for 2023 showed the Medical Director did not attend the QAPI meeting 3 of 4 quarters for months which an attendance roster was available. Review of the QAPI agenda attendance rosters for 2023 showed there were no attendance rosters maintained for 4 of 12 months of 2023. During an interview on 2/1/2024 at 10:05 AM, the Administrator in Training confirmed the former Medical Director had not attended the facility QAPI as required. Review of the facility policy and procedures titled Quality Assurance Performance Improvement Program (QAPI) last reviewed on 2/1/2024 showed the policy read, Procedure . 6. QAA [Quality Assessment and Assurance] Committee include but are not limited to: a) Executive Director, b) Medical Director/designee, c) Director of Nursing/designee, d) Infection Preventionist. 105413 Page 11 of 11