Health inspection·April 6, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm 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 record review, the facility failed to ensure a safe and sanitary homelike environment (photographic evidence obtained). Residents Affected - Few Findings include: During an observation on 4/3/2023 at 11:33 AM, Resident #39's room had a tube feeding pole that had formula like substance dripped on the pole, the feeding pump, the wall, the floor, and the floor mat. The far wall was separated from baseboard from a previous repair. During an observation on 4/3/2023 at 3:32 PM, Resident #39's room had a tube feeding pole with formula like substance dripped on the pole, the feeding pump, the wall, the floor, and the floor mat. The far wall was separated from baseboard from a previous repair. During an observation on 4/4/2023 at 10:51 AM, Resident #39's room had a tube feeding pole with formula like substance dripped on the pole, the feeding pump, the wall, the floor, and the floor mat. The far wall was separated from baseboard from a previous repair. During an interview on 4/4/2023 at approximately 3:00 PM, the Administrator stated, This should not be. I think nursing is supposed to clean the pole. I expect the housekeepers to clean the rooms every day. During an interview on 4/4/2023 at approximately 4:00 PM, the Director of Nursing (DON) stated, I see the formula on the pole. Housekeeping will not touch any medical equipment. The pole is medical equipment. Nurses only have wipes. Review of the facility policy and procedure titled Cleaning and Disinfection of Resident-Care Items and Equipment revised in September 2022 reads, Policy Statement: Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC [Centers for Disease Control and Prevention] recommendations for disinfection and OSHA [Occupational Safety and Health Administration] Bloodborne Pathogens Standard. Policy Interpretation and Implementation . 1 . c. Non-critical items are those that come in contact with intact skin but not mucus membranes. (1) Non-critical resident care items include bedpans, blood pressure cuffs, crutches, and computers . (3) Non-critical items require cleaning followed by either low- or intermediate-level disinfection following manufactures' instructions. Review of the facility policy and procedure titled Daily Patient Room Cleaning revised in 6/2016, reads, Timing & Method . 5) Damp mop floor with germicide solution damp mop floor working from back Page 1 of 15 105461 105461 04/06/2023 Aviata at Brentwood 2333 N Brentwood Cir Lecanto, FL 34461

F 0584 corner to door, Use Wet Floor sign when finished . Additional Information . The goal of cleaning is Infection Control. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 105461 Page 2 of 15 105461 04/06/2023 Aviata at Brentwood 2333 N Brentwood Cir Lecanto, FL 34461

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 resident assessment accurately reflected the resident's status for 1 of 3 residents sampled for discharge, Resident #101. Residents Affected - Few Findings include: Review of Resident #101's records revealed that the resident was admitted to the facility on [DATE] with the diagnoses including mood disorder, mixed anxiety disorders, hypertension, major depressive disorder and encounter for screening for respiratory tuberculosis. The resident was discharged on 2/15/2023. Review of Resident #101's progress note dated 2/15/2023 reads, Note Text: 14:50 [2:50 PM] discharge reviewed with patient, any questions answered to pt [patient] satisfaction. Medically, [Resident #101's Name] says she is well and ready to be discharged . Medications provided to patient. Valuable accounted for, inventory sheet signed. [Resident #101's Name] states her husband will be picking her up, when he gets off work so until then, she is remaining in room [room number]. Review of Resident #101's physician order dated 2/14/2023 reads, D/C [discharged ] home with HHC [Home Health Care], SN [Skilled Nursing] & PT [Physical Therapy] to eval [Evaluate] and treat. Review of Resident #101's Minimum Data Set (MDS) Discharge return not anticipated assessment dated [DATE] revealed the resident status as being discharged to acute hospital. During an interview on 4/4/2023 at 12:30 PM, Staff D, MDS Registered Nurse, confirmed that Resident #101's MDS discharge assessment dated [DATE] indicated that the resident was discharged to an acute hospital, but the resident was discharged home. Review of facility policy and procedure titled MDS revised on 9/25/2017 and reviewed on 1/18/2023 reads, Procedure . Specified sections of the RAI [Resident Assessment Instrument] process are completed by the center designated interdisciplinary Team Members. Each person completing a section or portion of a section of the MDS signs the Attestation Statement indicating its accuracy. 105461 Page 3 of 15 105461 04/06/2023 Aviata at Brentwood 2333 N Brentwood Cir Lecanto, FL 34461

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of Resident #11's medical records revealed the resident was admitted to the facility on [DATE] with diagnoses including heart failure, chronic obstructive pulmonary disease, and acute respiratory failure. During an observation on 4/3/2023 at 11:09 AM, Resident #11 was sitting in a wheelchair, wearing nasal cannula and receiving oxygen via condenser. The setting on the oxygen condenser was between 2.5-3.0 liters per minute. Oxygen tubing was not dated (photographic evidence obtained). During an observation on 4/3/2023 at 3:29 PM, Resident #11 was sitting on the side of the bed, wearing nasal cannula and receiving oxygen via condenser. The setting was between 2.5-3.0 liters per minute. Oxygen tubing was not dated. During an interview on 4/3/2023 at 3:30 PM, Resident #11 stated, I do not touch the settings. I just turn the condenser on/off. During an observation on 4/4/2023 at 8:30 AM, Resident #11 was wearing nasal cannula and receiving oxygen via condenser. The setting was between 2.5-3.0 liters per minute. Oxygen tubing was not dated. During an observation on 4/5/2023 at 1:31 PM, Resident #11 was eating lunch, wearing nasal cannula and receiving oxygen via condenser. The setting was at 3 liters per minute. Review of Resident #11's physician order dated 7/6/2022 reads, Respiratory: Oxygen - Continuous 2 L nc [nasal cannula] to maintain O2 stats above 92%. Review of Resident #11's care plan initiated on 8/31/2022 revealed no focus for oxygen administration. During an interview on 4/5/2023 at 12:20 PM, Staff E, LPN, MDS Coordinator, stated that oxygen should be on the care plan and it was not. Review of the facility policy and procedure titled Plans of Care dated 11/30/2014 and reviewed on 1/18/2023 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. Based on record review and interview, the facility failed to develop and implement a resident-centered care plan to meet the residents' needs for oxygen administration for 4 of 13 sampled residents, Residents #11, #12, #70 and #97. Findings include: 1. Review of Resident #97's medical records revealed the resident was admitted to the facility on 105461 Page 4 of 15 105461 04/06/2023 Aviata at Brentwood 2333 N Brentwood Cir Lecanto, FL 34461

F 0656 Level of Harm - Minimal harm or potential for actual harm [DATE] with diagnoses including heart failure, atrial fibrillation, memory deficit following cerebral infarction, major depressive and anxiety disorder. During an observation on 4/3/2023 at 11:46 AM, Resident #97 was receiving oxygen via concentrator machine running at 2 liters per minute, with no date on the tubing. Residents Affected - Few During an observation on 4/4/2023 at 8:14 AM, Resident #97 was receiving oxygen via concentrator machine running at 2 liters per minute, with no date on the tubing. Review of Resident #97's physician order dated 2/24/2023 reads, Change tubing, mask and/or nasal cannula weekly. May change sooner as needed. As needed for hygiene. Review of Resident #97's care plan dated 2/28/2023 revealed no focus on addressing administration of oxygen. During an interview on 4/5/2023 at 1:18 PM, the Director of Nursing confirmed that Resident #97's did not have a care plan for oxygen administration. 2. Review of Resident #12's medical records revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, asthma, angina, and heart failure. During an observation on 4/3/2023 at 10:18 AM, Resident #12 was receiving oxygen at 4.5 liters per minute via nasal cannula. During an observation on 4/3/2023 at 3:22 PM, Resident #12 was receiving oxygen at 4.5 liters per minute via nasal cannula. During an observation on 4/4/2023 at 8:34 AM, Resident #12 was receiving oxygen at 2 liters via nasal cannula. Review of Resident #12's physician order dated 2/9/2023 reads, O2 [oxygen] at 2 Liters as needed for O2 sat [saturation] below 92%. Resident #12's physician orders included no order for changing oxygen tubing or rate of oxygen flow. Review of Resident #12's care plan revealed no focus for oxygen delivery and monitoring. During an interview on 4/4/2023 at 3:52 PM, Staff E, LPN, Minimum Data Set (MDS) Coordinator, stated, I have visually seen her with oxygen and seen her take it off. Staff E stated, A care plan for respiratory and oxygen therapy needs to be written. 3. Review of Resident #70's medical records revealed the resident was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, pulmonary edema, anemia, and anxiety. During an observation on 4/3/2023 at 10:40 AM, Resident #70's oxygen tubing had no date. During an observation on 4/3/2023 at 3:33 PM, Resident #70 was receiving oxygen at 2 liters minute via nasal cannula. Nasal cannula tubing was not dated. 105461 Page 5 of 15 105461 04/06/2023 Aviata at Brentwood 2333 N Brentwood Cir Lecanto, FL 34461

F 0656 Level of Harm - Minimal harm or potential for actual harm During an observation on 4/4/2023 at 9:00 AM, Resident #70 was receiving oxygen at 2 liters per minute via nasal cannula. Nasal cannula tubing was not dated. Review of Resident #70's physician order dated 6/20/2022 reads, Oxygen as needed PRN [as needed] at 2 L [Liter] via nasal cannula as needed for shortness of breath. Residents Affected - Few Review of Resident #70's care plan revealed no focus for oxygen delivery and monitoring. During an interview on 4/4/2023 at 3:52 PM, Staff E, LPN, MDS Coordinator, stated that no care plan was written for oxygen therapy. Staff E stated, A care plan for respiratory and oxygen therapy needs to be written. 105461 Page 6 of 15 105461 04/06/2023 Aviata at Brentwood 2333 N Brentwood Cir Lecanto, FL 34461

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 Based on observation, interview, and record review, the facility failed to ensure residents received care and services for midline catheter dressing change in accordance with professional standards of practice for 1 of 1 resident with midline catheters, Resident #6. Residents Affected - Few Findings include: During an observation on 4/3/2023 at 11:07 AM, Resident #6 was lying in bed with midline catheter noted on left upper arm with the dressing dated 3/26/2023. Clear dressing was noted and secured. Under transparent dressing, there was dry dark blood noted around insertion site (photographic evidence obtained). During an observation on 4/5/2023 at 3:06 PM, Resident #6 was lying in bed with the midline catheter dressing dated 3/26/2023. Clear dressing was noted and secured. Under transparent dressing, there was dry dark blood noted around insertion site. Review of physician order dated 3/24/2023 for Resident #6 reads, Change Dressing on admission or 24 hours after insertion and weekly thereafter and PRN [as needed]. Every evening shift every Fri [Friday]. During an interview on 4/5/2023 at 3:30 PM, the Director of Nursing stated that the dressing was dated 3/26/2023 and should be changed as ordered weekly. Review of the facility policy and procedure titled Central Vascular Access Device (CVAD) Dressing Change last revised on 6/1/2021 reads, Guidance: 1. Perform sterile dressing changes using Standard-ANTT [Aseptic Non Touch Technique]: 1.1 Upon admission 1.1.1 If transparent dressing is dated, clean, dry, and intact, the admission dressing change may be omitted and scheduled for 7 days from the date on the dressing label . 1.2 At least weekly. 105461 Page 7 of 15 105461 04/06/2023 Aviata at Brentwood 2333 N Brentwood Cir Lecanto, FL 34461

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation and interview, the facility failed to ensure the resident environment remained free of accident hazards by failing to ensure oxygen tanks were stored securely (photographic evidence obtained). Residents Affected - Few Findings include: During an observation on 4/3/2023 at 10:40 AM, there were two oxygen tanks in Resident #70's room, not secured in oxygen holders. During an observation on 4/3/2023 at 3:33 PM, there were two oxygen tanks in Resident #70's room, not secured in oxygen holders. During an interview on 4/3/2023 at 3:33 PM, Resident #70 stated, I use oxygen and use the oxygen tanks when I go outside, so I keep the tanks in here. One is empty and one is full. 105461 Page 8 of 15 105461 04/06/2023 Aviata at Brentwood 2333 N Brentwood Cir Lecanto, FL 34461

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 care consistent with professional standards of practice for 12 of 13 residents reviewed, Residents #6, #11, #12, #28, #44, #58, #59, #68, #70, #97, #98, and #204. Residents Affected - Some Findings include: 1. Review of Resident #28's medical records revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, other pulmonary embolism without acute Cor Pulmonale (a condition that causes the right side of the heart to fail), essential (primary) hypertension, congenital pneumonia, sleep apnea, and longstanding persistent atrial fibrillation. During an observation on 4/3/2023 at 9:38 AM, Resident #28 was lying in bed, receiving oxygen via nasal cannula at 2 liters per minute. During an interview on 4/3/2023 at 9:38 AM, Resident #28 stated, I use 2 liters of oxygen. During an observation on 4/4/2023 at 9:52 AM, Resident #28 was lying in bed, receiving oxygen via nasal cannula at 2 liters per minute. Review of Resident #28's physician orders revealed no order for oxygen administration. During an interview on 4/4/2023 at 2:34 PM, Staff C, Licensed Practical Nurse (LPN), stated, [Resident #28's name] does not have a current order or a care plan for oxygen. They are currently being administered oxygen and have an oxygen concentrator in their room. 2. Review of Resident #6's medical records revealed the resident was initially admitted on [DATE] and readmitted on [DATE] with the diagnoses including essential (primary) hypertension, heart failure, unspecified atrial fibrillation, and wheezing. During an observation on 4/3/2023 at 10:05 AM, Resident #6 was in bed, wearing a nasal cannula with oxygen being administered at 2 liters per minute. During an interview on 4/3/2023 at 10:05 AM, Resident #6 stated, My oxygen should be set to 2 liters per minute. On 4/4/2023 at 10:28 AM, Resident #6 was in bed, wearing a nasal cannula with oxygen being administered at 2 liters per minute. Review of Resident #6's physician orders revealed no order for oxygen administration. During an interview on 4/4/2023 at 2:36 PM, Staff C, LPN, stated, [Resident #6's name] does not have a current order or a care plan for oxygen. During an interview on 4/4/2023 at 3:03 PM, the Director of Nursing (DON) stated, My expectation is that anyone in the building receiving oxygen should have an order before we administer oxygen. 105461 Page 9 of 15 105461 04/06/2023 Aviata at Brentwood 2333 N Brentwood Cir Lecanto, FL 34461

F 0695 Level of Harm - Minimal harm or potential for actual harm During an interview on 4/4/2023 at 3:23 PM, the Executive Director stated, It is my expectation that anyone receiving oxygen continuously or PRN should have a physician order. 3. Review of Resident #12's medical records revealed the resident was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, asthma, angina, and heart failure. Residents Affected - Some During an observation on 4/3/2023 at 10:18 AM, Resident #12 was receiving oxygen at 4.5 liters per minute via nasal cannula. There was no date on the tubing. The nebulizer tubing was lying on the side table not covered and tubing was not dated. During an observation on 4/3/2023 at 3:22 PM, Resident #12 was receiving oxygen at 4.5 liters per minute via nasal cannula. Nebulizer tubing was lying on the side table not covered and the tubing was not dated. During an observation on 4/4/2023 at 8:34 AM, Resident #12 was receiving oxygen at 2 liters via nasal cannula. There was no date on the tubing for nasal cannula or nebulizer tubing. The nebulizer was lying on the table not covered. Review of Resident #12's physician order dated 2/9/2023 reads, O2 [oxygen] at 2 Liters as needed for O2 sat [saturation] below 92%. Resident #12's physician orders included no order for changing oxygen tubing or rate of oxygen flow. During an interview on 4/4/2023 at 3:52 PM, Staff E, LPN, Minimum Data Set (MDS) Coordinator, stated, I have visually seen her with oxygen and seen her take it off. Staff E stated, A care plan for respiratory and oxygen therapy needs to be written. 4. Review of Resident #44's medical records revealed the resident was admitted on [DATE] with diagnoses including asthma, shortness of breath, anemia, heart failure, and atherosclerotic heart disease. Review of Resident #44's physician orders revealed no orders for oxygen administration and no orders for oxygen tubing to be changed. During an observation on 4/3/2023 at 10:46 AM, Resident #44 was lying on his back with oxygen being administered at 2 liters per minute via nasal cannula, with no date on the tubing. During an interview on 4/3/2023 at 10:46 AM, Resident #44 stated, I am always on oxygen. During an observation on 4/3/2023 at 3:27 PM, Resident #44 was being administered oxygen at 2 liters per minute via nasal cannula, and the oxygen tubing was not dated. During an observation on 4/4/2023 at 8:36 AM, Staff A, LPN, North Wing Manager, confirmed that oxygen was being delivered at 2 liters per minute via nasal cannula and there was no date on the nasal cannula oxygen tubing. 5. Review of Resident #70's medical records revealed the resident was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, pulmonary edema, anemia and anxiety. Review of Resident #70's physician order dated 6/20/2022 reads, Oxygen as needed PRN [as needed] at 105461 Page 10 of 15 105461 04/06/2023 Aviata at Brentwood 2333 N Brentwood Cir Lecanto, FL 34461

F 0695 2 L [Liter] via nasal cannula as needed for shortness of breath. Level of Harm - Minimal harm or potential for actual harm During an observation on 4/3/2023 at 10:40 AM, Resident #70's oxygen tubing had no date. Residents Affected - Some During an observation on 4/3/2023 at 3:33 PM, Resident #70 was receiving oxygen at 2 liters per minute via nasal cannula. Nasal cannula tubing was not dated. During an observation on 4/4/2023 at 9:00 AM, Resident #70 was receiving oxygen at 2 liters per minute via nasal cannula. There was no date or time noted on the tubing. During an interview on 4/4/2023 at 9:00 AM, Staff A, LPN, North Wing Manager, stated, The oxygen tubing is not dated. I had the staff go through the department last night and label a plastic bag and hang the bag on all concentrators. 6. Review of Resident #58's medical records revealed the resident was admitted on [DATE] with diagnoses including diabetes mellitus, chronic obstructive pulmonary disease, and atrial fibrillation. Review of Resident #58's physician orders reads, Order Summary: Respiratory: Oxygen @ [at] 2 L [liters] via n/c [nasal cannula] continuous . Start Date: 06/28/2021 . Order Summary: Change tubing, mask and/or nasal cannula weekly. May change sooner as needed. As needed for hygiene . Start Date: 06/28/2023 . Order Summary: Resident tolerance of nebulizer treatment (Add corresponding code in supplementary documentation. Good= G, Fair= F, Poor= P every 6 hours as needed. Start Date: 07/08/2021. During an observation on 4/3/2023 at 10:23 AM, Resident #58 was sitting in a wheelchair in the hall with oxygen being administered via nasal cannula from portable oxygen tank set at 1 liter per minute. Nasal cannula tubing was not labeled. The nebulizer mask and tubing were lying on the table, not dated and not covered. During an observation on 4/3/2023 at 2:10 PM, Resident #58 was receiving oxygen at 1 liter per minute via nasal cannula on portable tank. There was no date on the oxygen tubing. Nebulizer mask and tubing were lying on the table, not dated and not covered. During an observation on 4/3/2023 at 3.22 PM, Resident #58 was receiving oxygen from concentrator via nasal cannula at 1 liter per minute. The tubing was not dated. The nebulizer mask and tubing were lying on the table, not dated and not covered. During an interview on 4/4/2023 at 8:34 AM, Staff A, LPN, North Wing Manager, confirmed that the oxygen rate was set at 1 liter, there was no date on the tubing for nasal cannula or nebulizer, and the nebulizer was not covered. During an interview on 4/4/2023 at 8:52 AM, Staff A, LPN, North Wing Manager, stated, The tubing was not changed and was not labeled as ordered. I had the night shift change all the tubing and place the clear bag with the date on it, last night. They were supposed to change all the nebulizer mask and place them in a bag. They missed this one. Oxygen tubing changes are done on night shift normally on Friday night. CNAs [Certified Nursing Assistants] or PCAs [Personal Care Attendants] change tubing and date the bag. 7. Review of Resident #68's medical records revealed the resident was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, acute respiratory failure, arrhythmias, 105461 Page 11 of 15 105461 04/06/2023 Aviata at Brentwood 2333 N Brentwood Cir Lecanto, FL 34461

F 0695 atherosclerosis, heart failure, obstructive sleep apnea, cardiomegaly, anxiety, and anemia. Level of Harm - Minimal harm or potential for actual harm Review of Resident #68's physician order dated 6/20/2022 reads, Change tubing, mask and/or nasal cannula weekly. May change sooner as needed . Oxygen @ 3 L via n/c Cont. [continuously] every shift. Residents Affected - Some During an observation on 4/3/2023 at 9:56 AM, Resident #68 was lying in bed with oxygen being administered at 2 liters per minute via nasal cannula. There was no date noted on the oxygen tubing. During an interview on 4/3/2023 at 9:56 AM, Resident #68 stated, I think the setting is 3. I don't change it. I can't get out of bed myself. The oxygen tubing is only changed if needed. It's not changed weekly. During an observation on 4/3/2023 at 3:16 PM, Resident #68 was receiving oxygen at 2 liters per minute via nasal cannula. There was no date noted on the oxygen tubing. During an observation on 4/4/2023 at 7:48 AM, Resident #68 was receiving oxygen at 2 liters per minute via nasal cannula. There was no date noted on the oxygen tubing. During an interview on 4/4/2023 at 8:08 AM, Staff F, LPN, stated, Oxygen is checked by the nurse during medication administration for rate. Only the nurses adjust the oxygen. Aids can change the tubing. Oxygen tubing is changed normally Thursday or Saturday nights. During an interview on 4/4/2023 at 8:32 AM, Staff A, LPN, North Wing Manager, confirmed that the oxygen rate was at 2 liters per minute. 8. Review of Resident #59's medical records revealed the resident was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, and dependence on supplemental oxygen. Review of Resident #59's physician orders dated 4/3/2023 reads, Respiratory oxygen 2-3 L continuous NC [Nasal Cannula]. During an observation on 4/3/2023 at 10:28 AM, Resident #59 was lying in bed with nasal cannula prongs lying on the resident's left side of his cheek, not in nares. Oxygen was being delivered via nasal cannula at 1.5 liters per minute. The nebulizer was lying on table, not covered and not dated. During an interview on 4/3/2023 at 10:28 AM, Resident #59 stated, I use oxygen all the time. Tubing is changed when it starts to bother me, or it gets dirty. During an observation on 4/3/2023 at 3:27 PM, Resident #59 was being administered oxygen at 1.5 liters per minute via nasal cannula. The tubing was not dated, and the nebulizer was lying on table, not covered and not dated. During an interview on 4/4/2023 at 8:34 AM, Staff A, LPN, North Wing Manager, confirmed that Resident #59's oxygen rate was at 1.5 liters per minute and there was no date on tubing for nasal cannula or nebulizer tubing. During an interview on 4/4/2023 at 8:52 AM, Staff A, LPN, North Wing Manager, confirmed that the tubing was not changed and was not dated per facility policy for Resident #12, Resident #44, Resident 105461 Page 12 of 15 105461 04/06/2023 Aviata at Brentwood 2333 N Brentwood Cir Lecanto, FL 34461

F 0695 Level of Harm - Minimal harm or potential for actual harm #58, Resident #70, Resident #68 and Resident #59. Staff A confirmed that there were no orders for oxygen tubing to be changed for Resident #12 and Resident #59. During an interview on 4/5/2023 at 1:52 PM, Staff E, LPN, MDS Coordinator, stated that the residents that were using oxygen required a physician order. Residents Affected - Some During an interview on 4/5/2023 at 4:24 PM, the DON stated, My expectation is that orders are followed at the rate of flow ordered and that tubing is changed on Friday nights and all tubing is dated at that time. All Residents receiving oxygen therapy need a physician order for oxygen and rate of delivery. Also, an order for oxygen tubing to be changed weekly and as needed is required for all residents receiving nebulizer treatments. 10. Review of Resident #97's medical records revealed the resident was admitted to the facility on [DATE] with diagnoses including heart failure, atrial fibrillation, memory deficit following cerebral infarction, major depressive and anxiety disorder. During an observation on 4/3/2023 at 11:46 AM, Resident #97 was receiving oxygen via concentrator machine running at 2 liters per minute, with no date on the tubing. During an observation on 4/4/2023 at 8:14 AM, Resident #97 was receiving oxygen via concentrator machine running at 2 liters per minute, with no date on the tubing. Review of Resident #97's physician order dated 2/24/2023 reads, Change tubing, mask and/or nasal cannula weekly. May change sooner as needed. As needed for hygiene. During an interview on 4/5/2023 at 1:18 PM, the DON confirmed that Resident #97's oxygen tubing and concentrator was not labeled or dated. 11. Review of Resident #98's medical records revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, atrial fibrillation, hypertension, major depressive disorder, and encounter for screening for respiratory tuberculosis. During an observation on 4/3/2023 at 11:01 AM, Resident #98 was sitting on the side of his bed with oxygen being administered at 3 liters per minute via nasal cannula with no label or date on the tubing. During an observation on 4/4/2023 at 8:48 AM, Resident #98 was lying in bed with oxygen being administered at 3 liters per minute via nasal cannula with no label or date on the tubing. Review of Resident #98's physician order dated 3/2/2023 reads, Change tubing, mask and/or nasal cannula weekly. May change sooner as needed. As needed for hygiene. During an interview on 4/5/2023 at 1:18 PM, the DON confirmed that Resident #98's oxygen tubing and concentrator were not labeled or dated. 12. Review of Resident #204's medical records revealed the resident was admitted to the facility on [DATE] with diagnoses including abnormalities of gait and mobility, dysphagia, type II diabetes mellitus, bipolar disorder, major depressive disorder, anxiety disorder, restless leg syndrome, and hypotension. 105461 Page 13 of 15 105461 04/06/2023 Aviata at Brentwood 2333 N Brentwood Cir Lecanto, FL 34461

F 0695 Level of Harm - Minimal harm or potential for actual harm During an observation on 4/3/2023 at 11:57 AM, Resident #204 was lying in bed with oxygen running at 3 liters per minute, with no date or label on the tubing. During an observation on 4/4/2023 at 8:35 AM, Resident #204 was lying in bed, being administered oxygen via nasal cannula at 3 liters per minute, with no label or date on the tubing. Residents Affected - Some Review of Resident #204's physician order dated 3/29/2023 reads, Change tubing, mask and/or nasal cannula weekly. May change sooner as needed. As needed for hygiene. During an interview on 4/5/2023 at 1:18 PM, the DON confirmed that Resident #98's oxygen tubing and concentrator were not labeled or dated. Review of the facility policy and procedure titled Oxygen Therapy reads, Procedure: Physician's order for oxygen therapy shall include: Administration modality, FiO2 [the concentration of oxygen in the gas mixture] or liter flow, Continuous or PRN [as needed], PRN orders must include specific guidelines as to when the resident is to use oxygen. Documentation shall include . Start O2 [oxygen] flowrate at the prescribed liter flow or appropriate flow for administration device . Label tubing and humidifier with date and time. 9. Review of Resident #11's medical records revealed the resident was admitted to the facility on [DATE] with diagnoses including heart failure, chronic obstructive pulmonary disease, and acute respiratory failure. During an observation on 4/3/2023 at 11:09 AM, Resident #11 was sitting in a wheelchair, wearing nasal cannula and receiving oxygen via condenser. The setting on the oxygen condenser was between 2.5-3.0 liters per minute. Oxygen tubing was not dated (photographic evidence obtained). During an observation on 4/3/2023 at 3:29 PM, Resident #11 was sitting on the side of the bed, wearing nasal cannula and receiving oxygen via condenser. The setting was between 2.5-3.0 liters per minute. Oxygen tubing was not dated. During an interview on 4/3/2023 at 3:30 PM, Resident #11 stated, I do not touch the settings. I just turn the condenser on/off. During an observation on 4/4/2023 at 8:30 AM, Resident #11 was wearing nasal cannula and receiving oxygen via condenser. The setting was between 2.5-3.0 liters per minute. Oxygen tubing was not dated. During an observation on 4/5/2023 at 1:31 PM, Resident #11 was eating lunch, wearing nasal cannula and receiving oxygen via condenser. The setting was at 3 liters per minute. Review of Resident #11's physician order dated 7/6/2022 reads, Respiratory: Oxygen - Continuous 2 L nc to maintain O2 stats above 92%. Review of Resident #11's physician order dated 7/6/2022 reads, Change tubing, mask and/or nasal cannula weekly. May change sooner as needed. As needed for hygiene. During an interview on 4/6/2023 at approximately 3:30 PM, the DON confirmed stated that the oxygen setting was 3 liter per minute. 105461 Page 14 of 15 105461 04/06/2023 Aviata at Brentwood 2333 N Brentwood Cir Lecanto, FL 34461

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. **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 labeled and stored in accordance with currently accepted professional principles and included the expiration date when applicable in 1 of 4 medication carts and 2 of 3 medication rooms reviewed. Findings include: During an observation of North Medication Room on [DATE] at 9:45 AM with Staff A, Licensed Practical Nurse (LPN), Unit Manager, there was one Aplisol syringe with an expiration date of [DATE] in the refrigerator (Photographic evidence obtained). During an interview on [DATE] at 9:45 AM, when asked about the expired medication in the refrigerator, Staff A, LPN, Unit Manager, stated, The staff should go through the refrigerator once a week. During an observation of 500 Unit Medication Cart on [DATE] at 9:45 AM with Staff B, Registered Nurse (RN), there were one unopened Humalog Kwik PEN with a label indicating to keep refrigerated until opened, two unlabeled Glargine Insulin Pens, and one unlabeled Lyumjev Kwik Pen (Photographic evidence obtained). During an interview on [DATE] at 9:55 AM, Staff B, RN, stated, I did not go through my cart this morning. I was off this weekend and should have done so. During an observation of South Medication Room on [DATE] at 9:55 AM with Staff A, LPN, Unit Manager, there was one opened vial of Humulin 70/30 insulin with no label. The vial contained less than ½ a vial of insulin (Photographic evidence obtained). During an interview on [DATE] at 9:55 AM, when asked about unlabeled medication, Staff A, LPN, Unit Manager, stated, The staff should label the vial once opened. During an interview on [DATE] at approximately 3:45 PM, the Director of Nursing stated, I was aware, that should not be the nurses know better, they should have dated and pulled out of dates. Review of the facility policy and procedure titled Storage and Expiration Dating of Medications, Biologicals with an effective date of [DATE] and revision date of [DATE] reads, Procedure . 4. Facility should ensure that medications and biologicals that: (1) have an expiration 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. 5. Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened or opened. 5.1 Facility staff may record the calculated expiration date based on date opened on the primary medication container. 105461 Page 15 of 15