Health inspection·March 10, 2022

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident was treated with respect and dignity in a manner and in an environment that promoted maintenance or enhancement of their quality of life for 1 of 5 residents with indwelling catheter, Resident #85, in a total sample of 37 residents. Findings include: During an observation on 3/7/2022 at 11:16 AM, Resident #85's Foley catheter bag, which contained yellow urine, was facing the door of the resident's room with no privacy bag covering the urine bag. During an interview on 3/7/2022 at 11:24 AM, Resident #85 stated, I did not know why my catheter bag is not covered. I didn't know it was supposed to be covered. It has not been covered since I have been here. During an interview on 3/7/2022 at 11:33 AM, Staff A, Licensed Practical Nurse (LPN), stated, I do not see a privacy bag on the resident's Foley catheter bag. The Foley catheter bag should be covered with a privacy bag. Review of Resident #85's records revealed the resident was last admitted to the facility on [DATE] with diagnoses to include pneumonia, unspecified organism, and type II diabetes. Review of the facility policy and procedure titled Catheterization, Male and Female Urinary last revised on 4/12/2021 reads, Male Catheterization: . Foley bag to be covered by a privacy bag to preserve dignity of resident. Page 1 of 9 105460 105460 03/10/2022 Aviata at North Florida 6700 NW 10th Place Gainesville, FL 32605

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 2 residents with urinary catheter, Resident #4, in a total sample of 37 residents. Findings include: During an observation on 3/7/2022 at 10:56 AM, Resident #4's catheter tubing was hanging on the side of the bed with visible sediment in the tubing. During an interview on 3/7/2022 at 10:57 AM, Resident #4 stated, They flushed my catheter last night like they do every night. During an observation on 3/8/2022 at 10:47 AM, Resident #4's catheter tubing was hanging on the side of the bed with visible sediment (Photographic evidence obtained). During an interview on 3/8/2022 at 1:19 PM, Staff B, Licensed Practical Nurse (LPN), verified there was sediment in the tubing and stated, Yes, it needs to be replaced. During an interview on 3/8/2022 at 1:55 PM, Staff D, Registered Nurse, Unit Manager for Unit 2, confirmed that the tubing for Resident #4's catheter needed to be changed due to the sediment observed in the tubing. She further stated that her expectation would be that when the nurse flushed the catheter, they would have noticed the sediment and changed the catheter tubing at that time. Review of Resident #4's records revealed the resident was admitted to the facility on [DATE] with diagnoses including idiopathic peripheral autonomic neuropathy, neuromuscular dysfunction of bladder, type 2 diabetes mellitus, quadriplegia, acquired absence of left leg below knee and major depressive disorder. Review of Resident #4's physician orders revealed the order dated 7/12/2019 for suprapubic catheter, every shift related to neuromuscular dysfunction of bladder, and catheter care every shift and as needed, the order dated 11/30/2021 for changing catheter as needed and the order dated 12/22/2021 for Foley irrigation with 60 cc sterile water every night shift. Review of Resident #4's care plan reads, Focus: [Resident #4's Name] has Supra Pubic Catheter: Diagnosis of: Neuromuscular dysfunction of bladder, neurogenic bladder, quadriplegia. History of UTIs [Urinary Tract Infections]. Date Initiated: 04/24/2019 . Interventions: Cath care as ordered . Change catheter bag and catheter as ordered. Date Initiated: 04/24/2019. Review of the facility policy and procedure titled Suprapubic Catheter Care dated 11/30/2014 and reviewed on 4/12/2021 reads, Procedure: . Make sure all dried drainage is cleansed from skin and catheter tubing. 105460 Page 2 of 9 105460 03/10/2022 Aviata at North Florida 6700 NW 10th Place Gainesville, FL 32605

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on record review and interview, the facility failed to ensure the attending physician documented in the resident's medical record the drug regimen recommendations made by a licensed pharmacist for 2 of 5 residents sampled for pharmacy consult reviews, Residents #45 and #55, in a total sample of 37 residents. Findings include: 1. Review of the pharmacy consultation report for June 1, 2021 through June 30, 2021 for Resident #55 revealed a recommendation made on 6/29/2021 for changing the administration time of Donepezil to once daily in the evening before bedtime. The report did not include the physician's response or signature. Review of the pharmacy consultation report for August 1, 2021 through August 31, 2021 for Resident #55 revealed a recommendation made on 8/31/2021 for increasing Donepezil to 10 mg (milligrams) once daily in the evening prior to bedtime. The report did not include the physician's response or signature. Review of the pharmacy consultation report for September 28, 2021 for Resident #55 revealed a repeated recommendation from 8/31/2021 for increasing Donepezil to 10 mg once daily in the evening prior to bedtime. The report did not include the physician's response or signature. Review of the pharmacy consultation report for October 1, 2021 through October 31, 2021 for Resident #55 revealed a repeated recommendation from 9/28/2021 for increasing Donepezil to 10 mg once daily in the evening prior to bedtime. The report did not include the physician's response or signature. Review of the pharmacy consultation report for January 1, 2022 through January 31, 2022 for Resident #55 revealed a repeated recommendation from 12/27/2021 for assessing the ongoing need for Nuedexta, discontinuing if clinical benefit has not been clearly established, and if Nuedexta is to be continued, documenting the indication for use and the specific target symptom(s) that the medication is intended to treat. The report did not include the physician's response or signature. Review of the pharmacy consultation report for February 1, 2022 through February 28, 2022 for Resident #55 revealed a recommendation made on 2/18/2022 for discontinuing Lorazepam, tapering as indicated, decreasing to 0.5 mg every 8 hours for 14 days, then 0.5 mg twice a day for 14 days, and if an alternative is clinically indicated, initiating escitalopram 10 mg once a day. The report did not include the physician's response or signature. During an interview on 3/9/2022 at 2:00 PM, the Administrator confirmed Resident #55's pharmacy consultation recommendations were not signed by the physician and not followed through in a timely manner.2. Review of the pharmacy consultation report for July 1, 2021 through July 31, 2021 for Resident #45 revealed a recommendation made on 7/29/2021 for administering Shingrix 0.5 milliliters intramascularly when available from the pharmacy with a second dose administered in 60 days, unless clinically contraindicated. The report did not include the physician's response or signature. During an interview on 3/9/2022 at 3:55 PM, the Director of Nursing confirmed that she could not locate confirmation of the attending physician's review of Resident #45 medication regimen 105460 Page 3 of 9 105460 03/10/2022 Aviata at North Florida 6700 NW 10th Place Gainesville, FL 32605

F 0756 recommendation on 7/29/2021. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled, Monthly Drug Regimen Review, dated 4/21/2017 and revised on 4/12/2021 reads, Procedure: Consultant Reports - 1 Recommendation per page. Non-Urgent: Report provided to the attending physician for timely response: Day 1-14 provide recommendation(s) to physician(s) for review and response. Day 15-21 the DON [Director of Nursing]/ designee will contact the physician(s) with any outstanding recommendations if no response from physician notify the Medical Director for further assistance. Residents Affected - Some 105460 Page 4 of 9 105460 03/10/2022 Aviata at North Florida 6700 NW 10th Place Gainesville, FL 32605

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were removed from active inventory and disposed of properly after expiration in accordance with currently accepted professional principles. Findings include: 1. On 3/9/2022 at 7:00 AM, the surveyor observed Medication Cart #3 located on the 200 Hall and found one bottle of Prednisone eye drops with an expiration date of 3/4/2022, one bottle of Combigan eye drops with an expiration date of 3/8/2022, and one bottle of Pro-Stat liquid protein supplement with an expiration date of 1/27/2022. During an interview on 3/9/2022 at 7:00 AM, Staff C, Registered Nurse (RN), confirmed the observed medications were expired. During an interview on 3/9/2022 at 7:10 AM, the Director of Nursing (DON) confirmed the medications were expired, and stated it was her expectation that all nurses were to check for expired medications and disposed of them prior to starting their medication pass. 2. On 3/7/2022 at 11:17 AM, the surveyor observed a Flovent inhaler on Resident #7 bedside table. During an interview on 3/7/2022 at 11:23 AM, Resident #7 stated, I need to give the nurse the inhaler back. She left it here for me to use. During an interview on 3/7/2022 at approximately 11: 25 AM, Staff B, Licensed Practical Nurse (LPN), stated, I gave [Resident #7's Name] the Flovent inhaler this morning [3/7/2022] to use. I forgot to get the inhaler back from the resident. Review of the facility policy number 5.3 titled, Storage and Expiration Dating of Medications, Biologicals, last revised on 1/1/2022 reads, Procedure: . 4. Facility should ensure that medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier . 17. Facility should destroy or return all discontinued, outdated/expired, or deteriorated medications or biologicals in accordance with Pharmacy return/destruction guidelines and other Applicable Law, and in accordance with Policy 8.2 (Disposal/Destruction of Expired or Discontinued Medication). 105460 Page 5 of 9 105460 03/10/2022 Aviata at North Florida 6700 NW 10th Place Gainesville, FL 32605

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 foods were stored, labeled and dated in 2 of 2 nourishment rooms in accordance with professional standards for food service safety and failed to ensure ice machine was in a sanitary condition. Findings include: On 3/8/2022 beginning at 9:24 AM, during the initial tour of the facility kitchen and two nourishment rooms in 100 Unit and 200 Unit, accompanied with the Kitchen Manager, the surveyor observed two fish fillet dinners, a half-filled water container, ice cream in a brown plastic bag, four white plastic bags and two brown plastic bags containing food items, which were not labeled or dated, in the freezer in 100 Unit nourishment room, and two brown plastic bags and two plastic bags and one clear bag containing food items in the refrigerator of 200 Unit nourishment room, which were not labeled and dated (Photographic evidence obtained). On 3/8/2022 at 9:50 AM, during the tour of 200 Unit nourishment room, the surveyor observed white substance around the front opening and inside the ice machine. There was a dark substance in the bottom white panel (Photographic evidence obtained). During an interview on 3/8/2022 at 9:50 AM, the Kitchen Manager verified the observations in nourishment rooms in 100 Unit and 200 Unit and the ice machine. Review of the facility policy titled External Food and Beverages dated 3/7/2022 reads, Policy: To reduce the change of food borne illness, spread of infection. Provide guidance on heating and reheating and the proper storage of food and beverages brought into the facility from external sources. Increase the quality of life of residents. Procedure: All food and beverages from external sources must be dated and labeled. 105460 Page 6 of 9 105460 03/10/2022 Aviata at North Florida 6700 NW 10th Place Gainesville, FL 32605

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on record review and interview, the facility failed to implement the plan of action to correct identified quality deficiencies related to changing and flushing catheters per physician order and documenting the care provided in the medical record for 4 of 5 residents with urinary catheters, Residents #4, #34, #40, and #432. Findings include: Review of the Plan of Correction submitted by the facility reads, F690 Bowel/ Bladder/ Incontinence- UTI [Urinary Tract Infection] . STEP 4: Quality monitoring of 5 residents based on current census to be completed by the DCS [Director of Clinical Services]/designee to ensure catheters are changed/flushed when indicated per physician order with documentation in the medical record 5 x weekly x 4 weeks, 3 x weekly x 4 weeks, then twice weekly and PRN [as needed] as indicated until substantial compliance is achieved. Review of the facility monitoring sheet read, Quality Assurance/Performance Improvement. Quality Review completed by [place for name] on [place for date]. Area being reviewed: F690/N201 Bowel/Bladder/Incontinence-UTI. Ongoing monitoring: Ensure catheters are changed/flushed when indicated per physician order with documentation in the medical record . Codes . (Yes)=Met (No)=Not Met (N/A) = Not applicable. Quality Indicators. Catheters are changed when indicated per physician order with documentation in the medical record. Catheters are flushed when indicated per physician order with documentation in the medical record. Review of the monitoring sheets revealed reviews were completed for Residents #4, #34, #40 and #432 on April 11, 12, 13, 14, 15, 18, 19, 20, 21, 22, 25, 26, and 27, and Yes was documented for all five residents next to both quality indicators on each day. During an interview on 4/27/2022 at 2:20 PM, the DCS stated, I have been doing the audits but was not auditing the correct thing. I was auditing to make sure there were orders in place for each resident with a catheter, not that the care was being documented. I need to change the way I do the audits. The DCS acknowledged the blanks in the TARs [Treatment Administration Records] of Residents #4, #40 and #432 and stated, The Unit Managers are supposed to check the MARs [Medication Administration Records] and TARs every shift. They tell me everything is fine. Everything is not fine. We have gone over and over the education. Everyone knows they need to provide the care and it needs to be documented. I think the care was done and just not documented. Documentation was part of the in-service training along with following the doctors' orders. Review of Resident #4's TAR for April 2022 showed no records documented for Foley irrigation with 60 cc sterile water every night shift on April 3, 6, 7, 9, 12, 13, 17 and 21, no records documented for suprapubic catheter every shift related to neuromuscular dysfunction of bladder on April 2, 3, 5, 7, 11, 12 and 15 for day shift and on April 3, 6, 7, 12, 13, 17 and 21 for night shift, and no records documented for catheter care every shift and as needed every 24 hours as needed for catheter care and catheter bag change for any days in April 2022. Review of Resident #34's TAR for April 2022 showed no records documented for irrigation of catheter to prevent blockage/leakage with 60 cc (milliliter) of normal saline every night shift every night shift for catheter patency on April 6 and 18, and no records documented for catheter care every 105460 Page 7 of 9 105460 03/10/2022 Aviata at North Florida 6700 NW 10th Place Gainesville, FL 32605

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few shift and as needed every shift, monitoring catheter for patency and drainage, and monitoring urine for signs and symptoms of infection, and if present, documenting and notifying the medical director every shift on April 6 and 18 for night shift. Review of Resident #40's TAR for April 2022 showed no records documented for catheter care every shift and as needed every shift, monitoring catheter for patency and drainage every shift, and monitoring urine for signs and symptoms of infection and if present, documenting and notifying the medical director every shift on April 9 for day shift and on April 2, 6, 16 and 18 for night shift, and no records documented for catheter care every shift and as needed, catheter bag change as needed, and irrigation of catheter for blockages/leakages with 5-10 cc of normal saline as needed for any days in April 2022. Review of Resident #432's TAR for April 2022 showed no records documented for catheter care every shift and as needed, monitoring catheter for patency and drainage, and monitoring urine for signs and symptoms of infection and if present, documenting and notifying the medical director every shift on April 20 for night shift, no records documented for catheter care every shift and as needed, and catheter bag change as needed on April 20, and no records documented for irrigation of catheter for blockage/leakage with 5-10 cc of normal saline as needed on April 18, 19, 20, 21, 22 23, 24, 25 and 26. During an interview on 4/27/22 at 3:32 PM, Staff M, Licensed Practical Nurse (LPN), stated, I was asked to bring this to you [signed statement related to providing catheter care to Resident #432]. I provided catheter care to [Resident #432's Name] on April 25th. I had a family emergency and had to leave in a hurry and left without documenting the care in the chart, but I did do the catheter care. During an interview on 4/27/2022 at 3:38 PM, Staff N, LPN, stated, [the DCS's Name] had me sign these and told me to bring them to you [signed statements related to providing catheter care to Residents #34 and #40]. I provided catheter care and monitored for patency, drainage and signs and symptoms of infection for [Names of Residents #34 and #40] on April 18th. I think this is the day it took over three hours to get into PCC [Point Click Care]. I'm an agency nurse and we only get temporary log-ins. After a certain number of days, they expire and have to be reactivated. I'm pretty sure this was the day I had to keep calling the support call center to try and get back in. I got behind in my documentation. I thought I got it all taken care of, but I guess not. During an interview on 4/27/2022 at 4:32 PM, Staff C, Registered Nurse (RN), Unit Manager, stated, I've been told I'm supposed to go through the MAR and TAR as part of my job. I'll be honest with you. I don't always have time and sometimes I forget. I just got in trouble last week for not doing it. Review of the statement signed by Staff N, LPN, read, I, [Staff N's Name] hereby acknowledge that catheter care was provided to resident, [Resident #34's Name] on 04/18/22. I failed to document in the medical record and I am aware that this practice is unacceptable . I also monitored catheter for patency and drainage and for s/s [signs and symptoms] of infection. Review of the statement signed by Staff N, LPN, read, I, [Staff N's Name] hereby acknowledge that catheter care was provided to resident, [Resident #40's Name] on 04/18/22. I failed to document in the medical record and I am aware that this practice is unacceptable . I also monitored catheter for patency and drainage and for s/s of infection. Review of the statement signed by Staff O, LPN, read, I, [Staff O's Name] hereby acknowledge that 105460 Page 8 of 9 105460 03/10/2022 Aviata at North Florida 6700 NW 10th Place Gainesville, FL 32605

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few catheter care was provided to resident, [Resident #432's name] on April 20/25, 2022. I failed to document in the medical record and I am aware that this practice is unacceptable. Review of the statement signed by Staff M, LPN, read, I, [Staff M's Name] hereby acknowledge that catheter care was provided to resident, [Resident #432's Name] on 04/25/22. I failed to document in the medical record and I am aware that this practice is unacceptable. Review of the facility policy and procedure tiled Performance Improvement Committee (Quality Assurance) dated 11/30/2014 and revised on 8/19/2020 reads, Policy: The Performance Improvement Committee will meet to review, recommend, and act upon activities of the facility, performance improvement teams and/or departmental activities. The committee shall direct all activities including approving proposed monitoring, evaluating and review of services. The committee will assure QAPI [Quality Assurance and Performance Improvement] activities have indicators and standards/thresholds for evaluation, that appropriate actions are implemented and that such correction has been evaluated by subsequent monitoring. Procedure: . 4. The completed indicators will be reviewed monthly by the Performance Improvement Committee for meeting threshold. Indicators outside of the threshold will be assigned by the committee to a Performance Improvement for further improvement processes. The Committee will monitor and oversee the Performance Improvement Teams. 5. The Committee will assign interdisciplinary performance improvement teams activities and monitor the team's progress. A Performance Improvement Team will be developed to collect and evaluate data and to plan and implement needed action under the direction of the Performance Improvement Committee. Teams may be comprised of representatives of the primary departments involved with the aspect of care or service being evaluated, other affected staff, residents/families, and other appropriate community/customer representatives . 8. The Performance Improvement Committee will utilize the PIP [Performance Improvement Plan] documentation guide to monitor and oversee the Performance Improvement Teams to ensure oversight, guidance and support is provided. The Committee will review the results of all Performance Improvement Teams through evaluating and monitoring activities and make appropriate recommendations. 105460 Page 9 of 9