Health inspection·August 22, 2024

F 0558 Reasonably accommodate the needs and preferences of each resident. 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 residents were transferred out of bed using mechanical lift for 1 of 3 residents reviewed, Resident #4. Residents Affected - Few Findings include: Review of Resident #4's admission record showed the resident was admitted on [DATE] with diagnoses including type 2 diabetes mellitus with diabetic neuropathy, essential hypertension, hyperlipidemia, obesity, depression, sleep apnea, muscle weakness, neuralgia and neuritis, Transient Ischemic Attack (TIA) and cerebral infarction, and anemia. Review of Resident #4's care plan showed the resident was at risk for decreased ability to perform ADLs (Activities of Daily Living) in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion and toileting related to activity intolerance, CVA (Cerebrovascular Accident), recent hospitalization, and recent illness. During an interview on 8/21/2024 at 10:00 AM, Resident #4 stated, The Hoyer lift had dead batteries for 3 days, Friday [8/16/2024], Saturday [8/17/2024], and Sunday [8/18/2024]. They were not able to get me out of bed. During an interview on 8/21/2024 at 2:15 PM, Staff H, CNA, stated, Each unit has charging stations in the clean utility room. We are having an issue with the batteries not charging. During an interview on 8/21/2024 at 2:22 PM, Staff I, CNA, stated, We check the batteries prior to using them. We are having an issue with the batteries. During an interview on 8/22/2024 at 10:10 AM, Staff J, Certified Nursing Assistant (CNA), stated that Resident #4 was assigned to her on Sunday (8/18/2024) and confirmed that she did not get the resident out of bed. She stated, I went to 3 other units looking for batteries [for mechanical lift] that were charged, and unable to find one. During an interview on 8/22/2024 at 10:19 AM, Staff K, CNA, confirmed that she did not get Resident #4 out of bed on 8/17/2024, and stated, I had him on Saturday [8/17/2024]. He has other options to get out of bed like the slide board, but he prefers to use the Hoyer. I went to another unit, the 500 Hall, but the batteries had very low charge and did not work when put on the Hoyer. During an interview on 8/22/2024 at 12:52 PM, with the Director of Nursing (DON) stated, Staff is expected to go to another area to get a battery for the Hoyer lift if the ones in their area are not Page 1 of 5 105465 105465 08/22/2024 Aviata at Arbor Springs 1501 SE 24th Rd Ocala, FL 34471

F 0558 functioning. I had not been informed that there was an issue. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 105465 Page 2 of 5 105465 08/22/2024 Aviata at Arbor Springs 1501 SE 24th Rd Ocala, FL 34471

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 and interview, the facility failed to provide a clean and homelike environment (Photographic evidence obtained). Residents Affected - Few Findings include: During an observation on 8/21/2024 at 10:22 AM, there was a dead brown small pest in a cobweb noted high on the left side of the bed directly below the ceiling tiles in Resident #5's room. During an interview on 8/21/2024 at 10:22 AM, Resident #5 stated, I don't want bugs in my room. During an observation on 8/21/2024 at 10:41 AM, the baseboard in Resident #1's room was peeling away from the wall and there were multiple dead brown small pests inside the baseboard. There were three dead brown small pests inside the cobwebs high on the walls. There were two dead brown small pests above the windows and one on the left side of the bed below the ceiling tiles, all three in cobwebs. During an interview on 8/21/2024 at 10:41 AM, Resident #1 stated, I see live bugs crawling all over especially in the bathroom. If they sprayed in here, I don't remember. I don't know if those bugs are alive or dead bugs on the walls, but they are gross. They should clean them off. During an observation on 8/21/2024 at 10:44 AM with Staff A, Housekeeper, there was a dead small brown pest in cobweb in the corner by the head of the bed in Resident #9's room. During an interview on 8/21/2024 at 10:44 AM, Staff A, Housekeeper, acknowledged the dead small brown pest in cobweb in the corner by the head of the bed in Resident #9's room. During an observation of Resident #1's and Resident #5's rooms on 8/21/2024 at 2:54 PM, with the Housekeeping Supervisor, he confirmed the dead bugs present in the cobwebs. During an interview on 8/21/2024 at 2:54 PM, the Housekeeping Supervisor stated, The rooms need to be cleaned and dusted. The floors and any touchable areas are to be cleaned every day. Cobwebs and bugs should be dusted away every day. The staff will have to look up high. We were treating one hall at a time, and I believe that plays a role in some of the rooms having bugs. I wonder if they are going into the ceilings. 105465 Page 3 of 5 105465 08/22/2024 Aviata at Arbor Springs 1501 SE 24th Rd Ocala, FL 34471

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 interview and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice when a dietary supplement for wound healing was not provided as ordered for 1 of 3 residents, Resident #2. Residents Affected - Few Findings include: Record review of Resident #2's clinical record revealed resident was admitted with diagnosis that included pressure ulcers, paraplegia, muscle wasting, and atrophy. Review of Resident #2's physician orders dated 8/14/2024 read Juven [a supplement that provides essential nutrients for wound healing] two times a day for supplement Juven 1 packet w/(with) 8 oz (ounces) water BID (twice a day). Review of Resident #2's Medication Administration Record (MAR) dated 8/1/2024 - 8/31/2024 revealed that Juven was not documented as administered on 8/16, 8/17, 8/18 (2 doses), 8/21 (2 doses), and 8/22. There was no documentation in the chart where the doctor or nutritionist was informed that Juven was not available and was not administered. During an interview on 8/21/2024 at 2:50 PM, Resident #2 stated, I'm really worried now about my wound. I am not receiving the drink that I am supposed to get twice a day to help my wounds heal. I don't know the name, its protein or something. They said [the facility] they didn't have any. During an interview on 8/22/2024 at 2:25 PM, Staff O, LPN stated that she was assigned to [Resident #2's Name] and he was not provided Juven because she did not have it on her cart, and she did not call and notify the physician to inform him that the medication was not given. During an interview on 8/22/2024 at 2:30 PM, Staff P, Dietician, stated, I was not told that Juven was not available. If Juven or any nutritional supplement is ordered and not available, the physician and the nutritionist needs to be contacted so, if necessary, a replacement can be ordered. I was not told that Juven was not available. During an interview on 8/22/2024 the Director of Nursing stated, I expect physician orders to be followed and if the order cannot be followed the physician is to be notified. 105465 Page 4 of 5 105465 08/22/2024 Aviata at Arbor Springs 1501 SE 24th Rd Ocala, FL 34471

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on interview and record review, the facility failed to ensure resident environment was free of accident hazards by failing to ensure locks on the beds worked for 1 of 3 residents reviewed for accidents, Resident #2. Findings include: During an interview on 8/31/2024 at 2:50 PM, Resident #2 stated, I tried to transfer to the bed from the wheelchair, which I have done for years. The bed was not locked. The bed moved and I fell to the floor. The bed would not lock. It was broke. Review of Work Order #5582 for Resident #2's bed dated 8/1/2024 showed it read, Room/Area: [Resident #2's room number] . Comments: bed wheels replaced 8/2/24. Review of Work Order #5641 for Resident #2's bed dated 8/13/2024 showed it read, Notes: Resident stated that the bed is not going down. It is causing resident to be unable to on his feet. During an interview on 8/22/2024 at 12:51 PM, the Maintenance Director stated, The bed would not lock, and an order was placed in TELLS [communication tool for maintenance work orders]. I do not have a routine schedule to routinely check the beds to make sure the wheels lock or the beds are functioning appropriately and are safe. When the residents or staff find a problem, the staff just place an order in TELLS and I fix whatever needs to be fixed. During an interview on 8/22/2024 at 3:10 PM, the Director of Nursing stated, [Resident #2's name] bed would not lock. An order was placed. I'm not sure that maintenance has a routine maintenance check for bed safety. During an interview via telephone on 8/22/2024 at 3:49 PM, Staff C, Registered Nurse, stated, [Resident #2's name] uses the bed and wheelchair to move by himself. Two days after he came from the hospital, I heard him yelling out and I went in to help him. He fell trying to transfer from the wheelchair to the bed. The bed was not working. It would not lock. Honestly, I do not check the beds to see if they lock. That's maintenance or other attending staff. If someone checks the beds, I don't know who it is. During an interview on 8/22/2024 at 4:00 PM, the Director of Nursing stated, It was identified that the bed would not lock. No correction plan was initiated after discovery that the bed would not lock, and the resident fell. No action plan was initiated to check the beds routinely to prevent in the future. No education was provided to staff on bed checks for functionality. 105465 Page 5 of 5