Health inspection·April 24, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on an interviews, and record reviews, the facility failed to develop and implement a care plan for 1 (Resident #38) of 2 residents reviewed for respiratory care. Residents Affected - Few Findings include: During an observation on 4/21/2025 at 9:48 AM, Resident #38 was lying in raised bed with head of the bed elevated watching television. CPAP device is in a labeled bag on top of dresser close to the wall and back from the bed out of reach of resident on right side of the bed. The Resident is bed bound and cannot move about in bed without assistance. Resident #38 has oxygen administered via nasal cannula at 4 liters per minute. During an interview on 4/21/2025 at 9:48 AM, Resident #38 stated, I have not been receiving CPAP therapy every night because some nurses forget to place the CPAP on me. I will wake up at 2 or 3 in morning and not have CPAP on me. Review of physician's orders on 4/23/2025 at 5:00 PM, Resident #38 did not have any orders for CPAP. During interview on 4/24/2025 at 11:25 AM, the Director of Nursing confirmed the care plan should include the use of a CPAP device for [Resident #38's Name]. Review of policy and procedure titled, Plans of Care, with a review date of 12/18/2024, reads, Policy: An individualized person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and/or resident representative(s) to the extent practicable and updated in accordance with state and federal regulatory requirements. Plan of care is to be maintained as part of the final medical record. Procedure: Develop a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing ,mental and psychosocial needs that are identified in the comprehensive assessment. The Individualized Person Centered plan of care may include but is not limited to the following: Resident's strengths and needs, Services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required by state and federal regulatory requirements, individualized interventions that honor the resident's preferences and promote achievement of the resident's goals. Page 1 of 4 105413 105413 04/24/2025 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 observations, interviews, and record reviews, the facility failed to ensure respiratory care was provided, consistent with professional standards of practice for 2 (Resident #38, #44) of 2 residents review for oxygen therapy and CPAP (Continuous Positive Airway Pressure) devices. Residents Affected - Few Findings include: During an observation on 4/21/2025 at 10:35 AM, Resident #44 was sitting on the side of his bed with oxygen at 4 liters per minute per nasal cannula. During an observation on 4/22/2025 at 10:55 AM, Resident #44 had oxygen at 4 liters per minute per nasal cannula. During an observation on 4/23/2025 at 12:10 PM, Resident # 44 had oxygen at 4 liters per minute per nasal cannula. Review of Resident #44's admission record documented the resident was admitted on [DATE] with diagnosis that included chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, and dependence on supplemental oxygen. Review of the physician's orders for Resident #44 dated 8/28/2024 read, Respiratory: Oxygen - 3L PRN (3 liters as needed) via nasal cannula. During interview on 4/23/2025 at 2:45 PM, Staff A, B Hallway Nurse Manager stated, [Resident #44's Name] should have his oxygen set as ordered at 3 liters per minute per nasal cannula not at 4 liters per minute per nasal cannula. During interview on 4/24/2025 at 8:40 AM, the Director of Nursing stated, It is expected that if the oxygen order is for 3 liters per minute per nasal cannula, the physician order should be followed. 2) During an observation on 4/21/2025 at 9:48 AM, Resident #38 was lying in raised bed with head of the bed elevated watching television. CPAP device is in a labeled bag on top of dresser close to the wall and back from the bed out of reach of resident on right side of the bed. The Resident is bed bound and cannot move about in bed without assistance. Resident #38 has oxygen administered via nasal cannula at 4 liters per minute. During an interview on 4/21/2025 at 9:48 AM, Resident #38 stated, I have not been receiving CPAP therapy every night because some nurses forget to place the CPAP on me. I will wake up at 2 or 3 in morning and not have CPAP on me. During an observation on 4/22/2025 at 9:50 AM, Resident #38 was sleeping with oxygen per nasal cannula at 4 liters per minute. During an observation on 4/23/2025 at 12:12 PM, Resident #38 was awake watching TV with oxygen per nasal cannula at 4 liters per minute. 105413 Page 2 of 4 105413 04/24/2025 Aviata at Brooksville 1445 Howell Ave Brooksville, FL 34601

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #44's admission record documented the most recent readmission date of 12/06/2024 with diagnosis that included chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia. Review of the physician's order for Resident #44 dated 12/7/2024 read, Respiratory: Oxygen - Continuous at 3 L (liters), may take off intermittently. During interview on 4/23/2025 at 2:45 PM, Staff A, B Hallway Nurse Manager stated [Resident #38's Name] should have her oxygen set as ordered at 3 liters per minute per nasal cannula not at 4 liters per minute. I did speak with [Resident #38's Name] about her not having her CPAP device placed on her at night. Review of physician's orders on 4/23/2025 at 5:00 PM, Resident #38 did not have any orders for CPAP. During interview on 4/23/2025 at 5:50 PM, the Director of Nursing confirmed there was not an order for CPAP for [Resident #38 Name] and stated, Resident should have an order for CPAP if therapy is being administered. During interview on 4/24/2025 at 8:40 AM, the Director of Nursing stated, It is expected that if the oxygen order is for 3 liters per minute per nasal cannula, the physician order should be followed for [Resident #38's Name]. Review of the policy and procedure titled, Physician Orders, last review date 12/18/2024, reads: Policy: The center will ensure that Physician orders are appropriately and timely documented in the medical record. Review of the policy and procedure titled, Oxygen Therapy, last review date 12/18/2024, reads: Policy: Oxygen therapy is the administration of a FiO2 [estimation of the oxygen content a person inhales], greater than 21%, by means of various administration devices to: raise the resident's PaO2 [measure the pressure of oxygen in the blood] to an acceptable baseline using he lowest FIO2, to treat arterial hypoxemia, to decrease work of breathing, to reverse and prevent tissue hypoxia, and/or to decrease myocardial work. Procedure: Physician's order for oxygen therapy shall include: Administration modality, FIO2 or liter flow, Continuous or PRN (as needed), PRN orders must include specific guidelines as to when the resident is to use the oxygen. Review physician's order . Start O2 flowrate at the prescribed liter flow or appropriate flow for administration device. 105413 Page 3 of 4 105413 04/24/2025 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 observations, interviews, and record review, the facility failed to ensure food was safely and properly thawed, stored, and labeled in accordance with professional standards for food service safety. Residents Affected - Some Findings include: An the initial tour of the kitchen on 4/21/25 at 9:10 AM with the Dietary Manager (DM), an observation was made in the walk-in cooler of 4 rolls (5 lbs. each) of thawed ground beef sitting in a deep pan of red watery liquid, 4 bags (10 lbs. each) of thawed raw chicken in a deep pan of red watery liquid 4 fully cooked hams (5 lbs. each) on a sheet pan and 4 raw turkey breasts all without a label for a pulled or use by date. During an interview on 4/21/25 at 9:20 AM, the DM state that he placed the meats on the rack in the cooler Friday when the truck delivered the food and should have been labeled the meats with the pull and used by date and the meal it was for. Review of the policy titled, Labeling and Dating Inservice, last reviewed on 12/18/2024 read, Purpose: To educate all new hires and current employees on the importance of and guidelines for proper labeling and dating. Guidelines for Labeling and Dating. All foods should be dated upon receipt before being stored. Items that are removed from a labeled case in the freezer and placed in the refrigerator for thawing should be labeled with the date if removal from the freezer and an appropriate use by date as outlined in the retention guide. Review of the document title, Food Storage Retention Guide, not dated read, Raw Meat/Poultry/Seafood: (Once Thawed). Fish, seafood, ground meat and all poultry. 1-2 days. Beef or pork roast, steaks or chops. 3-5 days. 105413 Page 4 of 4