Health inspection·May 4, 2022

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure care according to industry standards by not following physician's orders for quarterly lab draws for 1 (Resident #31) of 1 resident reviewed for seizures. Not following physician's orders for quarterly lab values puts a resident with seizure disorder at risk of seizures and hospitalization by not ensuring therapeutic levels of the seizure medication are within the bloodstream. Residents Affected - Few The findings included: On 5/1/22 at 10:06 a.m., Resident #31 was observed lying in bed in her room. The resident did not respond to verbal stimulation, stared straight ahead, making unintelligible noises, like whimpering. Review of the Minimum Data Set, dated [DATE] indicated Resident #31 had a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. The active diagnosis for Resident #31 included unspecified convulsions, seizure disorder, and anoxic brain injury. Resident #31 was originally admitted to the facility on [DATE]. Review of the active orders as of 4/1/22 for Resident #31 indicated orders for three different seizure medications: Keppra Tablet 750 milligrams (mg), give two tablets by mouth twice daily for unspecified convulsions was ordered on 9/14/20; Phenytoin (Dilantin) Infatab Chewable 50 mg, give two tabs by mouth four times a day for unspecified convulsions was ordered on 10/14/21; Valproate Sodium Solution 250 mg/5 milliliters (ml) by mouth twice daily for unspecified convulsions was ordered on 7/20/21. The active orders also included an order dated 9/17/20 to draw lab values to monitor the blood levels of Keppra, Phenytoin (Dilantin) and Valproic Acid (Valproate Sodium) every three months. On 5/1/22 at 7:00 p.m. during a telephone interview with Resident #31's mother, she said Resident #31 had a seizure a couple of weeks ago at the facility and was admitted to the hospital. She said Resident #31's blood level for the seizure medication was checked when she got to the hospital and two of three seizure medications were lower than the therapeutic range. Review of the nursing progress note dated 4/17/22 indicated Resident #31 was admitted to the hospital emergency department for seizure symptoms and discharged back to the facility on 4/19/22. Review of the hospital records for Resident #31 indicated Blood levels for Phenytoin (Dilantin) collected by the hospital on 4/17/22 at 1:17 p.m. were 5.63, below the therapeutic range of 10 - 20. Blood levels for Valproic Acid collected by the hospital on 4/18/22 at 11:36 a.m. were 25.65, below Page 1 of 10 105507 105507 05/04/2022 Aviata at North Fort Myers 991 Pondella Rd N FT Myers, FL 33903

F 0684 the therapeutic range of 50 - 100. Level of Harm - Actual harm Review of the Medication Administration Records from January 2022 through April 17, 2022, indicated Resident #31 did not miss any doses of her seizure medication at the facility. Residents Affected - Few Review of the facility laboratory reports for Resident #31 indicated blood levels for Keppra, Phenytoin, and Valproic Acid were done on 10/14/21. Lab values were due again in January 2022 and April 2022. Review of the facility laboratory reports for Resident #31 indicated there were no blood level results for Keppra, Phenytoin (Dilantin), or Valproic Acid in the facility medical record for January 2022, February 2022, March 2022, or April 2022 before Resident #31 went to the hospital for the seizure on 4/17/22. On 5/3/22 at 11:20 a.m., Unit Manager Staff J said all lab results are in the computer. She said she did not see the results for the seizure medications in January 2022 or April 2022 before Resident #31 went to the hospital for the seizure. On 5/3/22 at 11:50 a.m., Resident #31's mother said the resident does not go out for blood draws and has them done at the facility. On 5/3/22 at 11:58 a.m., Medical Records Staff K said there were no lab reports in the paper chart in the medical records department for Resident #31, and she did not possess the missing lab reports. On 5/3/22 at 12:24 p.m., the Director of Nursing (DON) said she did not see the lab results that were due for Resident #31 every 3 months after October 14, 2021, in the computer or paper chart. On 5/3/22 at 3:25 p.m., the DON said she called the laboratory, and she can only assume the labs were not done. On 5/4/22 at 10:19 a.m., Advanced Registered Nurse Practitioner Staff A said you want to keep the seizure drugs in the therapeutic ranges to decrease the chance of seizures. She said the blood draws should have been done every 3 months. She said, It is a ding on her because she did not monitor the lab results. 105507 Page 2 of 10 105507 05/04/2022 Aviata at North Fort Myers 991 Pondella Rd N FT Myers, FL 33903

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide appropriate services and interventions for the management of contractures for 1 Resident (Resident #92) of 5 residents reviewed with limited range of motion. The findings included: Record review for Resident #92 showed an occupational therapy Discharge summary dated [DATE] noting Resident #92 was discharged to nursing for long term care. The discharge recommendations included bilateral hand splints. The therapy communication to restorative program form dated 4/21/22 included to don a left-hand splint on Tuesdays, Thursdays and Saturdays and a right-hand splint on Mondays, Wednesdays an Fridays. The form specified Day time, pt [patient] may remove. The instructions for the splints noted the expected outcome was to preserve range of motion and finger extension; correct finger contracture; palmar integrity; inhibit fingernail access. On 5/2/22 at 9:19 a.m. and 2:12 p.m., Resident #92 was observed without hand splints. On 5/2/22 at 2:12 p.m., Resident #92 said she is supposed to wear hand splints, and it was hard to put them on both hands, I need help. Resident #92 said The last time I wore them is when I was receiving occupational therapy. On 5/2/22 at 3:42 p.m., Certified Nursing Assistant (CNA) Staff D, said she had never seen Resident #92 wearing splints and did not know she needed to wear them. On 5/2/22 at 3:45 p.m., CNA Staff E said he has seen Resident #92 with splints on once last month when she was working therapy but not recently. On 5/3/22 at 10:47 a.m., Registered Nurse (RN) Staff C said she has not seen Resident #92 with splints and splints were not listed on the treatment sheets. On 5/3/22 at 11:33 a.m., Certified Occupational Therapist Assistant (COTA) Staff F said Resident #92 verified Resident #92 was not wearing the hand splints. Staff F said Resident #92 completed her therapy on 4/18/22 and was referred to a functional maintenance program. She said it was concerning Resident #92 was not wearing the splints. On 5/3/22 at 4:03 p.m., the Director of Nursing (DON) said the splints were not added to the Treatment Administration Record for Resident #92, therefore the nursing staff would not have known about the splints. On 5/4/22 at 9:40 a.m., the Restorative CNA Staff H, said COTA Staff F took her to the resident's room on 5/3/22, showed her where the splints were and told her Resident #92 was supposed to wear them. COTA Staff F also gave her a note indicating the time to apply and remove both splints. 105507 Page 3 of 10 105507 05/04/2022 Aviata at North Fort Myers 991 Pondella Rd N FT Myers, FL 33903

F 0688 Level of Harm - Minimal harm or potential for actual harm On 5/4/22 at 10:03 a.m., COTA Staff F said Resident #92's splinting program had not been implemented since discharge from Occupational Therapy on 4/18/22. On 5/4/22 09:48 a.m., the Director of Rehabilitation (DOR) said there was a break in communication. Residents Affected - Few 105507 Page 4 of 10 105507 05/04/2022 Aviata at North Fort Myers 991 Pondella Rd N FT Myers, FL 33903

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 observation, record review, resident and staff interview the facility failed to document and follow up on grievances and ensure staff provided care and services to prevent skin injuries to 1 (Resident #94) of 1 resident observed with multiple skin tears to the hands. The findings included: Review of Personal Appearance, Dress code and Name badge (HR-305) policy and procedure with an effective date of 11/30/2014 noted, .Fingernails should be clean and well groomed. Employees who provide direct patient care and dietary employees should not wear fingernails beyond the end of the finger for safety and infection control. The facility's policy and procedure for skin tears-abrasions and minor breaks, care of, revised September 2013 read, . When an abrasion/skin tear/bruise is discovered, complete a Report of Incident/Accident.Reporting. Notify the responsible family member. Physician notification may be routine (that is, non-immediate) if abrasion is uncomplicated or not associated with significant trauma. On 5/1/22 at 10:14 a.m., Resident #94 was observed with 4 band aids to both hands. Resident #94 said she got those bruises and skin tears from staff with long fingernails. Resident # 94 said on 4/30/2022 she reported the incident to the Assistant Business Office Manager (ABOM). On 5/1/22 at 11:43 a.m., the ABOM said Resident #94 told her one of the Certified Nursing Assistants (CNA) grabbed her and one of her nails cut her hands. She said she reported it to her supervisor. The ABOM said she has observed direct care staff with very long and unsafe nails. Review of medical records on 5/2/22 showed the most recent weekly skin integrity review form was completed on 4/21/22 and showed Resident #94's skin was intact. On 5/2/22 at 8:59 a.m., the Director of Nursing (DON) said she asked the nurse to complete a skin evaluation. On 5/2/22 at 9:11 a.m., the facility completed a weekly skin integrity review form which noted Resident #94 had two small skin tears to the back of the left hand with redness around. On 5/3/22 at 3:41 p.m., the Director of Nursing (DON) said she was not aware of the incident for Resident #94. The DON said Resident #94 told her she sustained the skin tears from the staff with long fingernails. She said it was against the facility's dress code to have long fingernails particularly when providing direct care, an event should have been initiated to investigate and it was not done. 105507 Page 5 of 10 105507 05/04/2022 Aviata at North Fort Myers 991 Pondella Rd N FT Myers, FL 33903

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on record review, Resident, staff, and Practitioners interviews, the facility failed to ensure 1 (Resident #92) of 6 resident reviewed for unnecessary medications was free of significant medication errors. Residents Affected - Some The findings included: On 5/1/22 at 10:34 a.m., Resident #92 said her Sinemet for Parkinson's disease is scheduled for 5:00 p.m., and staff did not administer it to her until 7:30 p.m. She said she gets the Sinemet so late it causes her to have tremors. Resident #92 said she complained about receiving her Sinemet late to the Director of Nursing (DON) and the Advanced Practice Registered Nurse, but nothing is being done. On 5/1/22 at 1:32 p.m., record review for Resident #92 showed the following physician's orders: Sinemet CR Tablet Extended Release 25-100 MG (milligrams) (Carbidopa-Levodopa ER) give 1 tablet by mouth at bedtime at 9:00 p.m. for Parkinson and give 1 tablet by mouth two times a day for Parkinson at 9:00 a.m., and 5:00 p.m. The physician's orders also included to administer Carbidopa-Levodopa 25/100 1 tablet by mouth four times a day at 7:00 a.m., 11:00 a.m., 2:00 p.m., and 5:00 p.m. Review of medication records revealed the following documentation: 3/3/2022 Carbidopa-Levodopa Tablet 25/100 mg scheduled for 5:00 p.m., was given at 7:45 p.m. 3/3/2022 Sinemet CR Tablet extended release 25/100 scheduled for 5:00 p.m., was given at 7:45 p.m. 3/3/2022 Sinemet CR Tablet extended release 25/100 scheduled for 9:00 p.m. was given at 6:25 a.m. 3/4/22 Carbidopa-Levodopa Tablet 25/100 mg, scheduled for 11:00 a.m., was given at 12:34 p.m. 3/11/22 Sinemet CR extended Release 25/100 scheduled for 9:00 a.m., was given at 10:22 a.m. 3/16/22 Sinemet CR Extended release 25/100 scheduled for 9:00 p.m., was given at 11:30 p.m. 3/12/22 Carbidopa-Levodopa Tablet 25/100 scheduled for 11:00 a.m., was given at 2:39 p.m. 3/18/22 Carbidopa-Levodopa Tablet 25/100 scheduled for 11:00 a.m., was given at 1:39 p.m. 3/18/22 Carbidopa - Levodopa tablet 25/100 scheduled for 2:00 p.m., was given at 1:56 p.m. 3/26/22 Carbidopa-Levodopa tablet 25/100 scheduled for 11:00 a.m., was given at 12:39 p.m. 4/1/22 Carbidopa-Levodopa tablet 25/100 scheduled for 11:00 a.m., was given at 1:17 p.m. 4/1/22 Sinemet CR Extended release 25/100 scheduled for 5:00 p.m., was given at 7:04 p.m. 4/7/22 Carbidopa-Levodopa tablet 25/100 scheduled for 5:00 p.m., was given at 7:40 p.m. 4/7/22 Sinemet CR Tablet Extended release 25/100 scheduled for 5:00 p.m., was given at 7:40 p.m. 105507 Page 6 of 10 105507 05/04/2022 Aviata at North Fort Myers 991 Pondella Rd N FT Myers, FL 33903

F 0760 4/7/22 Sinemet CR Tablet extended release 25/100 scheduled for 9:00 p.m., was given at 11:04 p.m. Level of Harm - Minimal harm or potential for actual harm 4/10/22 Sinemet CR Tablet extended Release 25/100 scheduled for 9:00 a.m., was given at 10:22 4/10/22 Carbidopa-Levodopa tablet 25/100 scheduled for 11:00 a.m., was given at 10:22 a.m. Residents Affected - Some 4/15/22 Carbidopa-Levodopa tablet 25/100 tablet scheduled for 11:00 a.m., was given at 1:08 p.m. 4/15/22 Carbidopa-Levodopa 25/100 tablet scheduled for 2:00 was given at 1:08 p.m. 4/22/22 Carbidopa-Levodopa 25/100 tablet scheduled for 5:00 was given at 7:40 p.m. 4/22/22 Sinemet CR Tablet Extended Release 25/100 scheduled for 5:00 p.m., was given at 7:40 p.m. 4/30/22 Sinemet CR Tablet extended Release 25/100 scheduled for 9:00 a.m., was given at 12:22 p.m. 5/1/22 Carbidopa-Levodopa 25/100 tablet scheduled for 11:00 a.m., was given at 8:05 a.m. On 5/3/22 at 10:41 a.m., Registered Nurse (RN) Staff C said it was very important to administer the Sinemet (Carbidopa-Levodopa) medication on time. The nurse said one of her residents who she identified as Resident #92 gets tremors when her medication is late''. On 5/2/22 at 9:49 a.m., the Advanced Practice Registered Nurse (APRN), Staff A said it was crucial for this medication to be administered on time. There may be a leeway of 30 minutes before or after scheduled time but no more. When given more than 30 minutes late, you see things you don't want to see. The APRN explained when the Sinemet is administered late, it can cause pain, more tremors and it is a huge discomfort for the resident. APRN Staff A said the resident had talked to her about that a while back and had brought it up to the nursing staff. On 5/2/22 at 10:42 a.m., APRN Staff B said it was medically necessary and important to closely follow dosing administration times daily for Resident #92's Parkinson's Disease management. On 5/4/22 at 9:07 a.m., the Consultant Pharmacist said, I agree with the APRNs and my fellow clinicians. This Medication should be given as close as the set time as possible. On 5/2/22 at 9:58 a.m., the Director of Nursing (DON) said Resident #92 had mentioned it to her she gets tremors when her medication is late. She said the nurses should have given Resident #92 the medication as ordered and followed the facilities protocol at a minimum (one hour before or after prescribed time). 105507 Page 7 of 10 105507 05/04/2022 Aviata at North Fort Myers 991 Pondella Rd N FT Myers, FL 33903

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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, review of facility policy and procedure, and staff interview, the facility failed to maintain medications secured in locked treatment carts to limit access to unauthorized personnel in 3 (Canterbury, [NAME], and [NAME]) of 4 units of the facility. The findings included: The Policies and Procedures for Medication and Medication Supply Storage and Disposal with effective date of 11/30/2014 states Medications will be kept in a medication cart that locks and keys are only accessible to the licensed personnel distributing medications. On 5/1/22 at 10:00 a.m., observed unlocked, unattended, and unsecured treatment cart at the Canterbury nurse's station. The drawers were unlocked and easily accessible. There was no staff located at the nurse's station. The cart was stocked with prescription and over the counter medications and dressing supplies. On 5/2/22 at 10:05 a.m., observed treatment cart at [NAME] nurses' station that was unlocked, unattended, and unsecured. There was no staff around. Observation of the cart drawers showed treatment supplies and multiple residents' prescription medications. On 5/3/2022 at 8:55 a.m. at the [NAME] Nurses station, observed unlocked, unattended, and unsecured treatment cart. The drawers contained over the counter and prescription medications for multiple Residents. On 5/3/2022 at 9:15 a.m., Licensed Practical Nurse (LPN) Staff S verified she left the cart unlocked, unsupervised. She said the carts are supposed to be kept locked. On 5/3/2022 at approximately 9:30 a.m., the Director of Nursing (DON), said all the treatment and medication carts are supposed to be locked at all times. She said she would re-educate her staff today. 105507 Page 8 of 10 105507 05/04/2022 Aviata at North Fort Myers 991 Pondella Rd N FT Myers, FL 33903

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to maintain the kitchen and nourishment room equipment in a safe and clean manner. The facility failed to ensure kitchen staff contain hair to prevent contamination of food. The findings included: Healthcare Services Group (HCSG) policy 027 revised May 2014 Staff Attire read, It is the center policy that all employees wear approved attire for the performance of their duties. Action Steps 1. The food service Director insures all staff members will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained. On 5/1/22 at 9:30 a.m., during a tour of the kitchen the following was observed: Walk-in cooler with boxes of food supplies stored on the floor of the cooler. Hand washing sink with grime, and black bio growth. Juice machine dispenser nozzle was on counter with the nozzle touching the counter where it could be contaminated. Tray of cornbread sitting on plastic container uncovered underneath kitchen table. Kitchen hood vents over stove and bakers' ovens with grime, debris, and rust, with trays of rolls uncovered underneath the vent hoods. Shelf under table where boxes of juice are stored soiled with grime and debris. Floors next to and behind ice machine soiled with grime, debris, remnants of paper napkins and disposable cups. Wall at the entrance to the kitchen cracked. On 5/1/22 at 9:40 a.m., Dietary Aide Staff M confirmed the juice machine dispenser nozzle sitting on the counter and it should be kept in the holder to prevent contamination. Staff M confirmed the food supplies was on the floor in refrigerator. He stated they are not to have food items stored on the floor On 5/1/22 at 9:55 a.m., Dietary Aide Staff N, confirmed the tray of cornbread was not covered and could be contaminated when left open underneath the table. On 5/1/22 at 11:25 a.m., observation of [NAME] nourishment room showed the refrigerator soiled, with grime, debris, food spillage, and food items in bag with no label or date. On 5/1/22 at 11:30 a.m., observation of Canterbury nourishment room refrigerator showed food items with no label or date, and a broken shelf in freezer. 105507 Page 9 of 10 105507 05/04/2022 Aviata at North Fort Myers 991 Pondella Rd N FT Myers, FL 33903

F 0812 Level of Harm - Minimal harm or potential for actual harm On 5/3/22 at 9:33 a.m., Certified Dietary Manager (CDM) Staff O said when she is not on duty Staff N is in charge of the kitchen and confirmed food should not be sitting under the prep table uncovered. Staff O confirmed there should be no food items stored on the floors in the walk-in cooler and or freezers, and the juice dispenser nozzle should be kept in its holder to prevent contamination. Staff O confirmed the hood vents were dirty with rust, grime and debris and uncovered food should not be kept underneath them. Residents Affected - Many On 5/4/22 at 11:00 a.m., observation of [NAME] Staff R in kitchen prepping lunch meal, checking and removing French fries from oven for lunch service. [NAME] Staff R had a beard and was not wearing a beard net. On 5/4/22 at 11:05 a.m., observation of Staff R taking Food temperatures with beard not wearing beard guard. On 05/3/22 at 11:12 a.m., observation of Staff R serving food for lunch meal on trays to be served to residents with beard and no beard guard On 05/3/22 at 11:14 a.m., Certified Dietary Manager (CDM) Staff P (from sister facility) said she was just observing the kitchen on the survey, confirmed Staff R's beard was not contained in a beard guard while performing duties in the kitchen. Staff P confirmed Staff R should be wearing a beard net in the kitchen to cover facial hair to prevent contamination of the food. On 5/3/22 at 11:15 a.m., CDM Staff O confirmed staff R's beard was not contained while serving food. She said facial hair should be contained in a beard guard. 105507 Page 10 of 10