Health inspection·March 24, 2021

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. 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, resident and staff interview, the facility failed to provide adaptive equipment necessary to promote psychosocial wellbeing for 1 (Resident #7) of 1 resident identified with a hearing deficit. Residents Affected - Few The findings included: On 3/21/21, review of the clinical record showed a quarterly Minimum Data Set (assessment of resident functional capabilities and health needs) completed on 3/16/21. The assessment noted Resident #7 required a hearing device and had moderate difficulty hearing. The plan of care initiated on 3/17/21 documented Resident #7 had a communication problem due to difficulty hearing with interventions to apply a right ear hearing aid. The Certified Nursing Assistant (CNA) resident care [NAME] specified the CNA was to apply the right ear hearing aid. On 3/21/21 at 9:09 a.m., during an initial observation Resident #7 was sitting in a wheelchair in her room, calling out and asking to have her hearing aid put in. On 3/22/21 at 9:16 a.m., during an observation Resident #7 was in her room in bed, she was calling out, I can't hear, I need my hearing aid put in. On 3/22/21 at 1:15 p.m., in an interview, Resident #7 said she wanted someone to put her hearing aid in and said she was not able to hear. Resident #7 was in her room, sitting in her wheelchair and the hearing aid was on the nightstand behind her and out of her reach. On 3/23/21 at 9:52 a.m., observation revealed the hearing aid for Resident #7 was on the nightstand and out of the resident's reach. Resident #7 said she could not hear and asked for the hearing aid. On 3/23/21 at 11:33 a.m., in an interview, CNA Staff B said she was assigned to work on Resident #7's hall very frequently and worked several days a week. Staff B said she worked with Resident #7 all the time and was aware Resident #7 had a hearing device for the right ear. Staff B confirmed she had not applied the hearing device for Resident #7. On 3/24/21 at 10:13 a.m., in an interview, Licensed Practical Nurse Staff A said the CNA's were responsible to assist residents with applying glasses and hearing aids daily and the task would be on the CNA care [NAME]. Page 1 of 9 105452 105452 03/24/2021 Aviata at Englewood 1111 Drury LN Englewood, FL 34224

F 0676 On 2/24/21 at 10:57 a.m., in an interview the Executive Director said the facility had no policy for the application of resident glasses or hearing aids. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 105452 Page 2 of 9 105452 03/24/2021 Aviata at Englewood 1111 Drury LN Englewood, FL 34224

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, policy review, and staff interview the facility failed to maintain the kitchen, nourishment rooms, and activity kitchen in a clean, safe, and sanitary manner that was in good repair by not having clean surfaces in food storage areas, clean surfaces on food preparation equipment, outdated/unlabeled food items, and not maintaining the ice machines in a manner to prevent potential contamination. The findings included: The facility's policy, Ice Machines and Ice Storage Chests, revised January 2012, stated Ice-making machines, ice storage chest/containers, and ice can all become contaminated by unsanitary manipulation by employees, residents and visitors and to help prevent contamination of ice machines Keep the ice scoop/bin in a covered container when not in use. On 3/21/21 at 10:05 a.m., during the initial kitchen tour the following observations were made: heavy accumulation of dust in ceiling vent at kitchen entrance; hole in wall by pipe in dry storage area; and storeroom ceiling vent dusty. The top of the dish machine was soiled with dry salts and debris, and a blue curtain laid on top of the dish machine. The hood above the dish machine was heavily corroded with rust and paint peeling from the metal. Storage/food transport carts had heavily rusted frames and the casters were soiled and rusted. On 3/21/21 at 10:05 a.m., and 3/23/21 at 11:05 a.m., observation revealed the walk-in freezer door did not completely close, creating an accumulation of icy condensation inside of the freezer door and frame. The shelves had debris under them, and floors were heavily stained/soiled. On 3/21/21 at 8:31 a.m., during an observation of south pantry, the area between counter and refrigerator was heavily soiled with spillage and debris and accumulated dust on edge of ice machine. There was broken drywall with a missing cove base behind ice machine with visible bio-growth. The floor was dirty and stained. The sink backsplash was visibly stained. On 3/22/21 at 8:58 a.m., during an observation of north pantry, the floor was heavily soiled with debris, wall was stained/soiled, the sides of the ice machine were soiled, the wall next to ice machine was damaged, and an ice scoop was being stored inside the ice machine. On 3/23/21 at 11:05 a.m., a tour of the kitchen was made with the Dietary Supervisor (DS) and the above concerns were again noted. She confirmed condensation was still present along the freezer door and it did not completely close. The DS said the issue with the freezer door had been ongoing for a couple months and several attempts had been made to repair it. Regarding the rusted equipment, the DS said she had removed 2 carts from use and confirmed the rusted legs of 3 of the carts were still in use. The south pantry was observed, and the DS confirmed there was no handle on the outside of the cover of the ice machine and difficult to close without placing her hand on the inside surface of the lid. Observation of the north pantry ice machine was made, and the DS confirmed there should not be an ice scoop inside the machine and removed it. The tops and sides of the machine still had a heavy accumulation of dust. The DS acknowledged the same issue with being unable to close the cover to the ice machine without potentially contaminating inside of lid. On 3/24/21 at 8:30 a.m., observation of the activity department kitchen revealed the refrigerator 105452 Page 3 of 9 105452 03/24/2021 Aviata at Englewood 1111 Drury LN Englewood, FL 34224

F 0812 had several outdated items: Level of Harm - Minimal harm or potential for actual harm An unopened jar of pizza sauce had a best by date of 9/13/19. **Photographic evidence obtained** Residents Affected - Many An open container of partially green parmesan cheese had a best by date of 7/2/19. **Photographic evidence obtained** An open container of lemon bite pastry had a labeled date of 12/27/20. **Photographic evidence obtained** The cabinet next to the refrigerator had 2 muffin pans soiled with dried food debris. The Activity Director (AD) said she had food related activities and kept those items in the refrigerator. She confirmed the outdated items and removed them from potential use by residents. The AD said she did not know when the muffin pans had been used. On 3/24/21 at 10:34 a.m., in an interview, the Dietary Supervisor and Registered Dietitian confirmed they did not have access to the refrigerator in the activity room and did not monitor it for outdated items. 105452 Page 4 of 9 105452 03/24/2021 Aviata at Englewood 1111 Drury LN Englewood, FL 34224

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility's policy for Administering Medications, revised [DATE], stated If a drug was withheld, refused or given at a time other than the scheduled time, the individual administering the medication should initial and circle the Medication Administration Record (MAR) space provided for that drug and dose. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication Topical medications used in treatments were recorded on the resident's Treatment Administration Record (TAR). On [DATE], a review of the clinical record for Resident #53 revealed a physician's order for the antihypertensive medication Hydralazine every 8 hours; the antihypertensive medication Lisinopril twice daily; the antidepressant medication Mirtazapine daily; the antihypertensive medication Terazosin at bedtime; the high cholesterol medication Atorvastatin daily; the muscle relaxant Methocarbamol 4 times a day; and the topical analgesic Biofreeze gel was ordered to be applied daily to the resident's knee. The Medication Administration Record (MAR) for [DATE] lacked documentation the 2:00 p.m., dose of Hydralazine was administered on 3/1 and the evening dose of Lisinopril being administered on 3/19. There was no documentation of the Biofreeze being applied on 3/5, 3/10, 3/12, 3/13, and 3/23. Review of the February 2021 MAR for Resident #53 revealed there was no documentation of the medications Mirtazapine, Terazosin, Atorvastatin, and bedtime doses of Hydralazine and Methocarbamol, being administered on 2/5. The February Treatment Administration Record (TAR) lacked documentation of the Biofreeze being applied topically on 2/1, 2/2, 2/3, 2/9, 2/12, 2/13, 2/15, 2/19, 2/23, and 2/26. Review of the [DATE] MAR for Resident #53 revealed there was no documentation of the medication Hydralazine being given on 1/11 at 2:00 p.m., on 1/12 at 10:00 p.m. and 1/22 and 1/25 at 2 p.m. There was no documentation of Methocarbamol being given on 1/26 at 1 p.m. The January TAR lacked documentation of the Biofreeze being applied topically on 1/8, 1/22, 1/26, 1/28, 1/29, and 1/30. 3. On [DATE] Resident #53's physician ordered treatment to the new open area on the resident's left heel. The area was to be cleaned with an antiseptic and a foam dressing to be applied every 48 hours. The resident's TAR lacked documentation of the dressing being done on 3/10 as ordered. On 3/12, the physician changed the dressing order to cleanse the left heel wound with normal saline, apply calcium alginate and a form dressing on each day shift. There was no documentation of the dressing being done on 3/12, 3/13, and 3/23. On [DATE] at 12:55 p.m., in an interview, the Regional Nurse confirmed there was no documentation of the treatment being done to Resident #53's left heel until [DATE] after the initial dressing was applied on [DATE]. 4. Review of the clinical record for Resident #60 revealed a physician's order for the nerve pain medication Gabapentin 3 times a day; and the antidepressant medication Zoloft daily. The MAR for February 2021 lacked documentation of the medication Gabapentin and Zoloft being administered the evening of 2/8. The MAR for [DATE] lacked documentation of these 2 medications being given on the evening 105452 Page 5 of 9 105452 03/24/2021 Aviata at Englewood 1111 Drury LN Englewood, FL 34224

F 0842 of 1/8. Level of Harm - Minimal harm or potential for actual harm On [DATE] at 1:17 p.m., in an interview, the DON said if a medication was not given then the reason code was to be noted on the MAR and this would prompt the nurse to write a progress note as to why. She confirmed the MARs for Resident #53 and Resident #60 did not indicate the reason for the medications being left blank. Residents Affected - Few Based on record review, policy review, and staff interview, the facility failed to properly document and maintain complete and accurate records in the areas of health status and treatments for 3 (Residents #90, #60, #53) of 19 records reviewed. The findings included: The facility's policy and procedure for discharged records (Document MR-135), last revised on [DATE] noted To ensure required discharge documentation in a resident's closed medical record is accurate, complete, dated and signed by the appropriate individuals . Check that the physician's order for discharge, transfer or release of body is written appropriately, signed, and dated. Check the final nurses' note for pertinent resident information which includes but is not limited to date and time of discharge, pronouncement if ceased to breathe/expired . final disposition. Check deceased resident's records for pertinent resident information, which includes but is not limited to notification of resident's family and physician, resident condition and vital signs prior to death and disposition of possessions and belongings. 1. On [DATE], during the record review of Resident #90's closed death record, it was discovered resident expired on [DATE]. No documentation was found in the resident record about the circumstances around the death event, how she was found or the event in the days and hours before the death. There was no documentation in the nursing progress notes the supervisor or doctor was called and informed of the resident's death. There was no written order to release the body to the funeral home. On [DATE] at 2:25 p.m., in an interview, the Director of Nursing (DON) said the nurse should have charted events surrounding the resident's death, any pertinent issues, call to the doctor and report of the death, family call and notification, when the funeral home was called or the deceased body was picked up. 105452 Page 6 of 9 105452 03/24/2021 Aviata at Englewood 1111 Drury LN Englewood, FL 34224

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and resident and staff interviews, the facility failed to maintain a safe, sanitary, and comfortable environment for residents, staff, and the public by not having clean surfaces; maintaining resident equipment in a sanitary manner; not repairing damaged shower rooms and pantry walls; and having heavily soiled/stained furniture in day room. Not maintaining a sanitary environment has the potential for cross contamination and biological growth (bio-growth). The findings included: On 3/21/21 at 12:40 p.m., in an interview, Resident #80 said he had osteomyelitis (infection of the bone) in his left foot, had daily dressing changes, and was on antibiotics. The resident said he was concerned about the housekeeping in his bathroom, the shower rooms, and worried about getting an infection in his foot again. On 3/21/21 at 10:49 a.m., 3/21/21 at 2:21 p.m., 3/22/21 at 8:45 a.m., and 9:09 a.m., while touring the facility the following was observed: room [ROOM NUMBER] had three unlabeled, uncovered wash basins being stored on floor and the base of toilet was heavily stained with black bio-growth. **Photographic evidence obtained** The ceiling vent at room [ROOM NUMBER]'s entrance was heavily soiled with hanging dust, a dresser edge was chipped with exposed wood, and there was an unlabeled wash basin on floor. **Photographic evidence obtained** room [ROOM NUMBER]. The base of the bedside table was heavily stained, there was an unmarked wash basin stored on the floor next to the toilet, an unlabeled, uncovered bedpan was stored on the handrail next to the toilet, and the vent in ceiling was heavily soiled with dust. room [ROOM NUMBER]. The wheelchair at the foot of Bed-A had a heavily stained foam cushion without a cover on the seat, the restroom doorjamb was rusted, and black bio-growth was present on the silicone at the base of the toilet. The ceiling vent at the room's entry and ceiling tile next to vent were heavily coated with dust. **Photographic evidence obtained** room [ROOM NUMBER]. A bottle of unlabeled body rinse was present on the handrail in restroom and an unlabeled uncovered urinal was laying on the tank of toilet. The closet door edges were delaminated with exposed wood. The ceiling vent at the room's entry had hanging dust. **Photographic evidence obtained** room [ROOM NUMBER]. The overbed table base was soiled and rusty, the restroom doorjamb was rusty, a urinal was being stored uncovered on the handrail next to the toilet, and dust was hanging from the 105452 Page 7 of 9 105452 03/24/2021 Aviata at Englewood 1111 Drury LN Englewood, FL 34224

F 0921 vent in the ceiling. Level of Harm - Minimal harm or potential for actual harm **Photographic evidence obtained** Residents Affected - Many room [ROOM NUMBER]. The floor mat was torn and soiled next to Bed-A. The edge of the dresser was delaminated with exposed wood. An unlabeled wash basin was stored on the floor of the restroom next to an uncovered toilet plunger under the sink. The ceiling tile around the sprinkler was delaminated in the restroom, the mirror was heavily de-silvered, the ceiling vent had hanging dust, and the towel bar was missing with exposed sharp edges on the bracket. The cove base was detached from wall next to the entrance door with sharp edges, and the walls were very marred. **Photographic evidence obtained** room [ROOM NUMBER]. Large clumps of dust were hanging from the ceiling vent at the room's entrance. **Photographic evidence obtained** room [ROOM NUMBER]. The floor was observed to be heavily stained with coffee. The resident's beside table base and top were also heavily soiled. On 3/21/21 at 2:06 p.m., Resident #28 said the coffee stain had been there for three days. room [ROOM NUMBER]. The bedside table was heavily soiled. The pole for the tube feeding machine and the bed frame were stained with tube feeding drippage. South shower room. Four unlabeled combs were observed together on the counter, soiled and stained grout in toilet room, a brown substance was present on the wall behind the toilet and in the front of toilet, the wall was cracked and crumbling at the first shower entrance, an unsecured oxygen tank was being stored on the floor next to the sink, the bedside commode covers were being stored on top of one another on the floor under the bench in shower stall 1, and wheelchair parts were on the floor under the bench. An overbed table had 2 nail clippers, an emery board, stacked, uncovered towels, and unlabeled body wash. Debris was present on the floor, two bedside commode buckets were stored on the floor in shower 2, an open container of body wash was stored on the floor, an open package with one razor blade was on the shelf in shower 3, soiled shower chairs, a commode bucket on floor shower 3, torn partially detached shower curtains, and a foul odor coming from drains. **Photographic evidence obtained** On 3/21/21 at 11:07 a.m., Licensed Practical Nurse (LPN) Staff D observed the unsecured oxygen tank, and confirmed it needed to be in a holder and not stored in the shower room. LPN Staff D said she had no knowledge of who placed the tank in the shower or to which resident the oxygen belonged. The North Shower room had a heavy accumulation of dust in the ceiling vents, the floors were heavily soiled with debris, open bottles of body wash were on a shelf, there was a missing towel bar with exposed sharp brackets on the wall of the shower, an uncovered dirty linen bin with soiled linen inside was present in the corner, a foul odor in shower stall 1, and the shower curtains were torn and missing hooks. 105452 Page 8 of 9 105452 03/24/2021 Aviata at Englewood 1111 Drury LN Englewood, FL 34224

F 0921 **Photographic evidence obtained** Level of Harm - Minimal harm or potential for actual harm South Pantry. The ice machine was visibly soiled with dust and debris, the walls had dried food debris on them and the ceiling vent was dusty, there was missing cove base behind the ice machine and refrigerator, the wall behind the ice machine had damaged drywall, and the floor was heavily soiled and had detached cove base. Residents Affected - Many **Photographic evidence obtained** North Pantry. Heavy accumulation of dust present on the ceiling vent, the pantry had food stains on the walls, the metal vent behind the refrigerator had large amount of dust, the floor had a lot of debris, and a hole was present in the wall behind the ice machine. **Photographic evidence obtained** South Nurses Station. A wall mounted fan was heavily soiled with hanging dust and the floor was noted to be heavily soiled with clumps of dust. North Nurses Station. The floor was heavily soiled with stains and clumps of dust. South Day Room. There was debris on the floor behind the TV cabinet and the floor was heavily soiled. North Day Room. There were two heavily soiled armchairs, and a missing section of floor tile with exposed concrete and debris. Public Restroom Female. The ceiling vent had a heavy accumulation of dust. Public Restroom Male. The ceiling vent had a heavy accumulation of dust and a brown stain was present on the wall 3/22/21 thru 3/24/21. On 3/24/21 at 8:30 a.m., a tour of the facility was conducted with the Maintenance Director and Housekeeping Supervisor (HS). The noted concerns were still present during the tour. The HS Supervisor said staff did not have an effective method to clean the dusty vents and would be looking into a better way to do this. She acknowledged it was difficult for the housekeeping staff to clean around resident items that were improperly being stored on the handrails and floor. 105452 Page 9 of 9