Health inspection·March 13, 2024

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on record review, facility policy review, and staff interview the facility failed to provide the advance beneficiary notice to 2 (Residents #24, and #27) of 3 sampled residents reviewed. Residents Affected - Some The findings included: Review of facility policy titled Advanced Beneficiary Notice (ABN), revised 11/10/2015, which states, Policy: An ABN will be utilized to notify resident of the possibility that Medicare will not pay for the item(s) or service(s) that are described in the form .The form will be reviewed with the resident or authorized representative . Procedure: 1. The facility will give a completed copy of the ABN far enough in advance that the beneficiary or representative has time to consider the options and make an informed choice . 2. The resident must comprehend the contents. If the resident is unable to comprehend the contents of the notice, it must be delivered to and signed by an authorized representative . If the resident refuses to sign the notice, the notice is still valid as long as the facility documents that the notice was given but the resident refused to sign. 3. In the event that the resident is not competent, an authorized representative acting on behalf of the resident shall be notified. On 3/11/24 at 1:55 p.m., Residents, #24, and #27, clinical records were reviewed for ABN. Resident #24 last covered day for Medicare Part A was 10/20/23. Resident #24 remained at the facility. Resident #27 last covered day for Medicare Part A was 1/21/24. Resident #27 remained at the facility. On 3/11/24 3:15 p.m., during an interview with the Business Office Manager (BOM) she said she had been with the facility since January 2024. The BOM said the Minimum Data Set (MDS) nurse, Staff H, was completing the Notice of Medicare Non-Coverage (NOMNC) and then giving them to her to scan into the clinical records. BOM said, I have not received any ABN forms from the MDS Nurse Staff H. On 3/11/24 at 3:30 p.m., interviewed MDS Nurse, Staff H, who confirmed she was completing the beneficiary notices. I was covering for the times we did not have a social worker. I completed the NOMNC but did not know I needed to complete the ABN. Confirmed she was covering the responsibility for several months and no residents discharged from Medicare services had received an ABN form while she was covering the responsibility. On 3/11/24 at 3:40 p.m., during an interview the Social Services Director (SSD) was asked about Page 1 of 24 105507 105507 03/13/2024 Aviata at North Fort Myers 991 Pondella Rd N FT Myers, FL 33903

F 0582 Level of Harm - Minimal harm or potential for actual harm process for ABN and replied, We need to do an ABN for anyone who stays in the facility after services end. The SSD did not know why Residents #24 and #27 did not receive the required ABN notice. On 3/11/24 at 3:52 p.m., interviewed the Facility Administrator who said he was unaware that the staff was not providing ABN forms as required. Residents Affected - Some 105507 Page 2 of 24 105507 03/13/2024 Aviata at North Fort Myers 991 Pondella Rd N FT Myers, FL 33903

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews and record review the facility failed to provide a safe, sanitary, and homelike environment in 3 (Canterbury, Buckinham and [NAME]) of 4 halls, as evidenced by dry wall damage in resident's rooms, damaged resident furnishings and rusted resident equipment. Failure to identify and complete needed repairs could cause safety and sanitary hazards to vulnerable residents. The findings included: On 3/10/24 during the initial tour of the rooms on the 100 hallway; observation revealed there was damage to the dry walls next to the bathroom and behind the resident's beds in rooms [ROOM NUMBER]; a large hole was noted in the dry wall next to the air conditioner unit in room [ROOM NUMBER]; and also noted were the over the bed tables in room [ROOM NUMBER] and 115 and the over the toilet commode chair in room [ROOM NUMBER] had multiple rusted areas. Review of the Maintenance Plan policy and procedure #ALF-1015, dated 11/30/14, stated the facility would ensure the continued maintenance of the building and grounds in a clean, orderly condition and in good repair. All equipment and furnishings would be maintained in good condition. When a staff member noticed an item needing repair, he/she would complete a work order request defining the area or item needing repair. The maintenance staff would review the log and make the appropriate repairs. Review of the Maintenance Log policy and procedures #M-210, dated 11/30/2014, stated all maintenance performed on the buildings and grounds should be documented clearly and succinctly and in an organized manner so that it may be monitored by the Executive Director at any time. On 3/13/24 at 11:53 a.m., a tour of the 100 hallway was conducted with the Director of Maintenance (DOM) and he confirmed the damage to the dry walls in rooms 106, 109, 112, 113 and the rusted resident equipment in rooms [ROOM NUMBERS] which had been observed during the initial room tour on 3/10/24. The DOM said all facility staff were required to document in the maintenance logbook, located at each nursing station, any facility damage, all areas needing repair and damaged residents' equipment and furnishings. He said the maintenance assistant, during his morning rounds, would collect the maintenance logbook from each nursing station and bring them back to the maintenance office where he reviewed and prioritized each items listed to ensure the appropriate repairs and/or replacements were completed in a timely manner. The DOM reviewed the maintenance log for the 100 hallway and said the facility staff did not document in the maintenance logbook as required and he was unaware of the room damage and the rusted resident equipment in rooms 106, 109, 112, 113 and 115 which caused the needed repairs and/or replacements not to be completed in a timely manner. On 3/10/24 during initial tour of [NAME] Hall, the following was observed: room [ROOM NUMBER] in the shared bathroom an unlabeled urinal was hanging from the towel rack. A bed pan with a mirror inside was on the toilet tank and a wash basin was on the floor. 105507 Page 3 of 24 105507 03/13/2024 Aviata at North Fort Myers 991 Pondella Rd N FT Myers, FL 33903

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some room [ROOM NUMBER] in the bedroom dirty linen was on the floor and 2 urinals without a name to identify who they belonged to were on the dresser in the shared room. Photographic evidence obtained. room [ROOM NUMBER] in the shared bathroom there were unlabeled personal items on the toilet top. There was black grime around the toilet base and cracked wall tiles under the sink. Photographic evidence obtained. room [ROOM NUMBER]-B the wall had been patched in area near the nightstand. There was a urinal with urine approximately ¾ full sitting on the nightstand with person effects. Photographic evidence Obtained. room [ROOM NUMBER] in the shared bathroom the toilet tank top was off. There was black grime around the base of the toilet. Personal items were stored on the sink. On 3/10/24 at 9:51 a.m., Licensed Practical Nurse (LPN) Staff W confirmed the findings in the bathroom of room [ROOM NUMBER] and placed the toilet tank top back on the toilet. She said she did not know why it had been removed but would notify maintenance. Photographic evidence obtained. Resident #71 residing in the 200 hall said he was a smoker and he had cigarettes on his nightstand. Resident #71 said he was able to light his own cigarettes and opened his nightstand drawer to reveal a cigarette lighter. Photographic evidence obtained. The Director of Nursing, the Regional Nurse Consultant and the Unit Manager Staff B were immediately notified of the lighter and removed it. room [ROOM NUMBER] there were patched marks on the wall around the window. The air conditioning unit had black grime and missing grout where it met the wall. Photographic evidence obtained. room [ROOM NUMBER]. On 3/10/24 at 9:28 a.m., observation of a live small brown insect in the bathroom sink. A wash basin was on the floor under the sink with two large brown insects on their back with legs in the air, not moving. There was a live brown crawling insect making a web from the sink to the wash basin. Several small insects were in the wash basin, not moving. On 3/10/24 at 9:29 a.m., Central Supply Staff D was in the hallway, and came into the room and verified the observation of the live and dead insects in the bathroom. Photographic evidence obtained. On 3/10/24 at 10:12 a.m., LPN Staff W verified the observation made in the bathrooms of rooms 225, 105507 Page 4 of 24 105507 03/13/2024 Aviata at North Fort Myers 991 Pondella Rd N FT Myers, FL 33903

F 0584 223, 213, 232, 229, and 204. Level of Harm - Minimal harm or potential for actual harm On 3/10/24 at 12:00 p.m., a second observation of room [ROOM NUMBER]'s bathroom revealed five live medium brown pests crawling from the sink. Residents Affected - Some On 3/10/24 at 12:21 p.m., observation of room [ROOM NUMBER]'s bathroom with the Administrator revealed a large brown crawling insect on the bathroom sink. On 3/10/24 at 3:28 p.m., observation of room [ROOM NUMBER] revealed the wall behind the bed had areas of patched holes, it was dirty and in need of repair. The wall had peeling paint and the wooden section of the wall was unattached in sections where the wood and the wall meet. On 3/12/24 at 9:47 a.m., in an interview the Maintenance Director verified the dirty wall and patched holes in room [ROOM NUMBER]. He said I have only been here a few weeks and there is such a turnover. All the rooms are like that behind the beds, all of them. I am working on cleaning and repairing them, but I can only do so much. The problem is the resident needs to be out of the room or discharged because the chemicals used, the smells they need to be out of the room. I have completed two rooms so far. Every day the maintenance logs are checked, and we remove the slips. If it something we can repair right away, we do it and I keep all the slips in a binder in my office. If it is something that will take several days, then we place the slip here in this continuing maintenance log. This log stays on the Maintenance cart until it is resolved. I am working on repairing the resident rooms. I am aware of the patched walls in the rooms, they were like that when I started here, I can only fix so much in a day. There is myself and an assistant maintenance person. On 3/10/24 at 10:43 a.m., observed in room [ROOM NUMBER] A wall damage and missing baseboard, over bed bedside table with missing trim and exposed particle material, and dresser missing drawer pulls. On 3/10/24 at 11:26 a.m., observed Resident #99's room air conditioning unit set for 70 degrees, actively blowing air but air does not feel cool to the touch. Resident #99, in an interview said the air conditioner was not working and only blows air but not cool air. I worry as the weather gets warmer. Resident #99 said the facility was aware the air conditioner has not worked for a couple of months. On 3/10/24 at 12:44 p.m., observed in room Resident #101's bedroom dresser with missing drawer. On 3/10/24 at 1:09 p.m., observed Resident #6's room bedside nightstand with missing drawer pull. Resident #6 was aware the drawer was broken saying, It still works. Resident did not know when the facility was going to fix the drawer. On 3/13/24 at 10:23 a.m., interviewed Registered Nurse Staff K about furniture and room disrepair. RN Staff K said, We have a maintenance book where we put any work orders needed. On 3/13/24 at 10:30 a.m., reviewed facility maintenance binder and did not see any work orders for room [ROOM NUMBER], or Residents #6, #101, and #99's rooms. On 3/13/24 at 11:35 a.m., toured identified rooms with the facility Administrator. Previous observations unchanged. The Facility administrator said, I have ordered more furniture but understand it's 105507 Page 5 of 24 105507 03/13/2024 Aviata at North Fort Myers 991 Pondella Rd N FT Myers, FL 33903

F 0584 Level of Harm - Minimal harm or potential for actual harm not acceptable. I did not know about the air conditioner but I can see that it is not blowing cold. I will get the maintenance director to check. On 3/13/24 at 12:33 p.m., during a tour of the Canterbury and [NAME] hallways with the Maintenance Director, the following observations were made: Residents Affected - Some A large hole in Resident #46's bathroom wall. A hole in the wall in Resident #62's room. Two small holes in the wall of the room and plaster of the ceiling in the bathroom of Resident #53's room. On 3/13/24 at 12:35 p.m., in an interview Resident #53 said the plaster fell off the ceiling when she was in the bathroom but did not fall on her. The Maintenance Director confirmed an area on the ceiling in the bathroom is missing plaster. A large area of plaster off the corner wall of Resident #84's room. Holes in the wall of Resident #83 room. The Maintenance Director said each nurse's station has a binder where staff documents the areas in need of repair. He said staff are not reporting issues with walls, ceiling or furniture. He said housekeeping also go in the rooms every day and should report the issues. 105507 Page 6 of 24 105507 03/13/2024 Aviata at North Fort Myers 991 Pondella Rd N FT Myers, FL 33903

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Based on record review, review of facility's policy and procedure, and staff interviews, the facility failed to ensure the accuracy of a Pre-admission Screening and Resident Review (PASRR) and make the necessary corrections for 1(Resident #37) of 1 resident with admitting diagnoses of mental illness. The findings included: The facility policy titled Preadmission Screening and Resident Review (PASSR) with a revision date of 11/8/2021 stated, The center will assure that all Serious Mentally Ill (SMI) and intellectually disabled (ID) residents received appropriate pre-admission screenings according to Federal/State guidelines. The purpose is to ensure that the residents with SMI or are ID receive the care and services they need in the most appropriate setting. It is the responsibility of the center to assess and assure that the appropriate preadmission screenings, either Level I or Level II, are conducted and results obtained prior to admission and placed in the appropriate section of the resident's medical record. Review of the admission Record for Resident #37 revealed an admission date of 9/6/2023. The documented medical history at the time of admission included a diagnosis of bipolar disorder, schizoaffective disorder, and dementia. The Minimum Data Set (MDS) revealed Resident #37 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. Resident #37 level I PASRR screen dated 9/4/23 documented no diagnosis or suspicion of serious mental illness or intellectual disability indicated. Level II PASRR evaluation not required. Review of Resident #37 Psychology Evaluation dated 9/28/2023 reason of referral/chief complaint states, Confused thinking/bipolar disorder and is currently on Zyprexa which is a brand name for olanzapine (an antipsychotic medication to treat mental disorders, including schizophrenia and bipolar disorder). Per staff the patient is displaying confused thinking and wandering behavior. Review of Psychiatry Subsequent Note dated 3/5/24 indicates that Resident #37 will continue with olanzapine for controlling schizoaffective disorder. On 3/11/24 at 3:57 p.m., in an interview the Director of Nursing (DON) revealed the process to fill out a PASRR falls to the DON when the resident enters the facility through the home. The facility reviews admission charts for accuracy the next day or on Monday, if falls on the weekend. If errors are made on the PASRR, it would get corrected and resent. The DON confirmed the level I PASRR was inaccurate and did not list the diagnoses of bipolar disorder, and schizoaffective disorder on the PASSR for Resident #37 dated 9/4/24. The DON said she will make the correction. 105507 Page 7 of 24 105507 03/13/2024 Aviata at North Fort Myers 991 Pondella Rd N FT Myers, FL 33903

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** On 3/13/24 a review of Resident #104's medical record revealed she was re-admitted to the facility on [DATE] from the hospital with a diagnosis of Cellulitis, Gout, Altered Mental Status, and a Stage 4 Sacrum Pressure Wound. Review of the initial care plan dated 11/07/23 noted it did not document the stage 4 pressure ulcer to Resident #104's sacrum and no goal(s) and/or interventions were initiated to address the stage 4 pressure ulcer. The Minimum Data Set (MDS) (a comprehensive clinical assessment tool), dated 11/12/23, identified in Section M - Skin Conditions, that Resident #104 had 1 stage 4 pressure ulcer. On 11/20/23 the initial wound care physician's progress note stated there was a stage 4 full thickness pressure ulcer to Resident #104's sacrum. The pressure ulcer measured 9 x 6.3 x 4.5 cm. A care plan for potential/actual impairment to skin integrity for a pressure wound to the sacrum was initiated on 3/05/24 with a goal and interventions listed to maintain or develop clean and intact skin. This care plan was not initiated until approximately 3 1/2 months after the pressure ulcer had been identified by the facility nursing staff. The Plan of Care policy and procedures #N-1015 with an effective date of 11/30/14 and revision date of 9/25/27 stated an individualized person-centered plan of care should be established by the interdisciplinary team (IDT) with the resident and/or representative(s) to the extent practicable and updated in accordance with state and federal regulatory requirements. The policy noted the Procedure was to: 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; Develop and implement an individualized person-centered comprehensive plan of care by the IDT . as determined by the resident's needs or as requested by the resident, and, to the extent practicable, . within 7 days after the completion of the comprehensive assessment (MDS); and The individualized person-centered plan of care may include but is not limited to the following: services to attain or maintain the resident's highest practicable physical, physical, mental, and psychosocial well-being. On 3/13/23 at 10:53 a.m., in an interview with the MDS Coordinator, she said, after she reviewed Resident #104's medical record, Resident #104 was readmitted with a stage 4 pressure ulcer to their sacrum on 11/07/24 and was currently being seen by the wound care physician. She confirmed the MDS IDT completed a 5-day MDS admission assessment on 11/12/23 and a quarterly MDS assessment on 1/03/24 but did not initiate a plan of care to address Resident #104's stage 4 sacrum pressure ulcer until 3/05/24 approximately 3 1/2 months after the pressure ulcer had been identified by nursing staff. She confirmed the facility did not develop and implement a comprehensive plan of care with measurable goals and interventions to address Resident #104's stage 4 sacrum pressure ulcer within 7 days after the completion of the 5-day admission assessment date 11/12/23 as required. Review of facility policy titled, Medication Management- Psychotropic Medications, revised 10/24/2022 which states Procedure: 4. Monitor behavior and side effects every shift utilizing the Behavior Monitoring Flow Record (BMFR) or electronic equivalent .11. Care plan to include person centered goals and non-pharmaceutical interventions. Update Care Plan as indicated. 12. Monitor resident's response to medication, including the effectiveness of the medication, and potential adverse consequences. 105507 Page 8 of 24 105507 03/13/2024 Aviata at North Fort Myers 991 Pondella Rd N FT Myers, FL 33903

F 0656 13. Monitoring should also include evaluation of the effectiveness of non-pharmacological approaches. Level of Harm - Minimal harm or potential for actual harm Review of clinical records for Resident #18 initially admitted to the facility 9/8/23 and most recent readmission [DATE] documented diagnosis including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, and anxiety. Reviewed medication orders which included Diazepam 2.5 milligrams (MG) insert 20 mg rectally every 8 hours as needed for anxiety/ agitation. Insert 1 suppository as directed by Physician ordered 12/11/2023 discontinued 3/13/24; Diazepam 2.5 MG insert 20 mg rectally every 8 hours as needed for anxiety/ agitation. Insert 1 suppository as directed by Physician ordered 3/13/24; Lorazepam oral tablet 0.5 MG give 1 tablet by mouth every 4 hours as needed for anxiety ordered 11/20/23 discontinued 3/5/24; ; Lorazepam oral tablet 0.5 MG give 1 tablet by mouth one time only for increase agitation for 1 day ordered 3/11/24 discontinued 3/12/24; Quetiapine Fumarate oral tablet 50 MG give 1 tablet by mouth three times daily for mood stabilizer ordered 1/15/24 discontinued 3/5/24; Quetiapine Fumarate oral tablet 50 MG give 1 tablet by mouth three times daily related to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, and anxiety ordered 3/5/24; Temazepam oral capsule 15 MG give 1 tablet by mouth for insomnia ordered11/14/23 discontinued 3/13/24; Temazepam oral capsule 15 MG give 1 tablet by mouth for insomnia ordered 3/13/24; Ziprasidone HCl oral capsule 80 MG give 1 capsule by mouth twice daily for schizophrenia ordered 1/15/24 discontinued 3/13/24. Reviewed February 2024 and March 2024 Medication Administration Record (MAR) and Treatment Administration Records (TAR) with no behavior monitoring documented in clinical record. Reviewed resident's most recent care plan 10/23/23. Care plan does not address the use of psychotropic medications and to monitor behavior related to use of psychotropic medications. Residents Affected - Few Reviewed of clinical records for Resident #102 initially admitted to the facility 8/2/23 and most recent readmission [DATE] documented diagnosis including dementia, depression, anxiety epilepsy and impaired balance. Reviewed medication orders which included the following psychotropic medications: Sertraline HCl oral tablet 25 MG give 1 tablet by mouth bedtime for MDD (Major Depressive Disorder) ordered 2/14/24; Trazadone HCl oral tablet 150 MG give 150 mg by mouth nightly for MDD related to insomnia ordered 2/13/24; Buspirone HCl oral Tablet 15 MG give 15 MG by mouth twice daily for anxiety ordered 10/4/23; Olanzapine oral tablet 2.5 MG give 1 tablet by mouth twice daily for delusions ordered 1/14/24. Reviewed February 2024 and March 2024 Medication Administration Record (MAR) and Treatment Administration Records (TAR) with no behavior monitoring documented in clinical record. Reviewed resident's most recent care plan 10/23/23. Care plan does not address the use of psychotropic medications and to monitor behavior related to use of psychotropic medications. On 3/12/24 at 8:52 a.m., interviewed Registered Nurse (RN) Staff F assigned to resident #18 who confirmed resident has dementia and is on medications to manage his behavior. On 3/12/24 at 11:16 a.m., RN Staff J interviewed who said resident #102 does not have any issues related to his medications. Asked if he monitored the resident for behaviors and RN said, We watch all of our residents. RN confirmed he does not chart behavior monitoring daily. On 3/12/24 at 1:55 p.m., interviewed Certified Nursing Assistant (CNA) Staff Y who confirmed resident has dementia saying, He can sometimes have behavior when he takes off his clothes or becomes agitated. On 3/13/24 at 8:29 a.m., interviewed RN Staff I who confirmed Resident #102 is stable and calm. RN Staff I said they only document if he acts up and if that happened, she would put a progress note in 105507 Page 9 of 24 105507 03/13/2024 Aviata at North Fort Myers 991 Pondella Rd N FT Myers, FL 33903

F 0656 the record. She does not do daily monitoring documentation. Level of Harm - Minimal harm or potential for actual harm On 3/13/24 8:57 AM interviewed assigned CNA Staff L caring for Resident #18 said he participates in activities but sometimes does stuff like taking off his clothing. Residents Affected - Few On 3/13/24 at 9:21 a.m., during an interview with the Director of Nursing (DON) who confirmed when psychotropic medications are ordered the orders are reviewed to ensure there is an appropriate diagnosis and monitoring for side effects by assigned nurse each shift is initiated. The monitoring is documented on MAR. The DON reviewed clinical records for resident #18 and #102 and confirmed the order to monitor for side effects was never placed. DON said the order for monitoring would trigger the care plan to be updated. The DON said she was the person responsible for ensuring the medication orders and monitoring orders had been placed and that she had not done them as expected. Asked what the risks for not monitoring the use of psychotropic medications were. DON replied, there are a number of issues including anticholinergic effects, reaction to med itself tardive dyskinesia, over sedated, hypervigilant, exacerbation of behaviors. On 3/13/24 at 9:54 a.m., during an interview with Minimum Data Set (MDS) nurse Staff H who said that they have behind on care planning since she and the other MDS nurse were covering many roles for the social services department. Saying, Corporate knows we were behind in care planning, and we have been playing catch up and we started 2 weeks ago to get everything caught up. MDS nurse Staff H confirmed both Resident #18 and Resident #102 should have been care planned for behavior monitoring on admission. MDS nurse Staff H said, As a nurse I would have put the order in on admission. Confirmed comprehensive care plan for Resident #18 was not completed to include monitoring for behavior or medication response. Care plan for Resident #18 was updated accurately 3/8/24 and Resident #102 was updated 3/5/24. MSD nurse Staff H said not having accurate care plans can potentially cause harm since care and the care plan are driven by the entered orders. On 3/13/24 at 11:16 a.m., interviewed RN Staff K who confirmed Resident #18 was on psychotropics. Asked if she documented the resident's behavior each shift. RN Staff K replied, He is stable we only document if he has a problem. Confirmed she does not document each shift. Based on observation, record review, review of facility policy and procedure review, and interviews, the facility failed to develop and implement a comprehensive individualized care plan for 4 (Residents #37, #104, #18, and #102) of 26 residents reviewed. The findings included: Review of the facility policy titled, Plans of Care, with a revision date of 9/25/2017, specified, 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. The development of 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. Develop and implement an individualized person-centered baseline plan of care within 48 hours of admission that includes, but not limited to, initial goals based on the admission orders, physician orders, dietary orders, therapy services, social services, PASARR recommendations, if applicable, and 105507 Page 10 of 24 105507 03/13/2024 Aviata at North Fort Myers 991 Pondella Rd N FT Myers, FL 33903

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few other areas needed to provide effective care of the resident that meets professional standards of care to ensure that the resident's needs are met appropriately until the comprehensive plan of care is completed. Develop and implement an individualized person-centered comprehensive plan of care by the IDT that includes the attending physician, a registered nurse (RN) with responsibility for the resident, a nurse aide with responsibility for the resident, a member of food and nutrition services staff, and other appropriate staff or professionals in disciplines as determined by the residents' [NAME] or as requested by the resident, and, to the extent practicable, the participation of the resident and resident's representative(s), within seven (7) days after completion of the comprehensive assessment (minimum data set, MDS). A review of the admission Record revealed Resident #37 was admitted to the facility on [DATE] with diagnoses including bipolar disorder, schizoaffective disorder, and dementia. The admission Minimum Data Set (MDS) assessment noted Resident #37 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated moderate cognitive impairment. Review of Resident #37's Care Plan initiated on 9/21/2023, did not have a comprehensive person centered care plan for antipsychotic medication with interventions, elopement risk/wanderer, smoking, anticoagulation medications and interventions, activities of daily living (ADLs), congestive heart failure, risks for falls, risk for pain, chronic kidney disease and potential for fluid and electrolyte balance, incontinent of urine, potential for shortness of breath, potential for skin impairment, and use of diuretic and risk for fluid volume imbalance. On 3/10/24 at 10:40 a.m. observed resident in room, sitting on bed and a strong ammonia like smell in the room. During an interview on 3/13/24 at 9:32 a.m. with the MDS Licensed Practical Nurse (LPN) Staff H and MDS LPN Staff N stated, to be honest, we were covering social worker work and they have been behind. They are doing catch up work now. Nurses do the base line care plan on paper then the MDS nurse builds upon it. A base line care plan is about 4 pages. The MDS LPN build a care plan by looking at the orders and working with IDT. The MDS LPNs revealed that nurses monitor psychotropic medications and side effects by following the physician order and then it is in the MAR for charting. The MDS LPN confirmed there is no order for side effect monitoring and Resident #37 has not been monitored for side effects per the resident's electronic record. During an interview on 3/13/24 9:53 a.m., the DON revealed the admitting nurse does the baseline care plan. The MDS LPNs will enter information into Point Click Care (PCC) (electronic records). The DON is aware of being behind because they are trying to do catch up work. The staff have been covering floor nursing, social work, and wherever else needed and fell behind on the MDS work. The DON confirmed there is no order to monitor side effects of psychotropic medication. The DON confirmed the nurses are not monitoring or documenting side effects of psychotropic medications. The care plan was not patient centered care. A comprehensive care plan was not completed for six months. 105507 Page 11 of 24 105507 03/13/2024 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 - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility policies and procedures, clinical record review and staff and resident interviews, the facility failed to follow procedures to thoroughly evaluate and analyze the fall incidents, for 1(Resident #19) of 2 residents. The facility also failed to ensure smoking material including lighters were securely stored for 1 (Resident #71) of 25 residents identified by the facility as currently smoking. The findings included: 1. The facility policy N-1259 Fall Management effective 11/30/14 (Revised 7/29/19) documented Residents are evaluated for fell risk. Patient centered interventions are initiated based on resident risk. Purpose: Is to identify residents at risk for falls and establish/modify interventions to decrease the risk of future falls and minimize the potential for a resulting injury. Fall Mitigation: Fall risk is based off results of the Fall Risk Evaluation. Fall Mitigation Strategies: Develop resident centered interventions based on resident risk factors. Update the residents care plan and Nurse Aide [NAME] with interventions. On 3/10/24 at 12:37 p.m., in an interview Resident #19 said she has had several falls recently and was grateful she was not injured. She said she had three falls this year, that she can remember. Review of the clinical record revealed Resident #19 had an admission date of 11/4/21 with diagnoses including schizoaffective disorder bipolar type, anxiety, diabetes mellitus, morbid obesity, diabetic polyneuropathy and overactive bladder. The Quarterly Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 2/9/24 documented Resident #71 was independent with ambulation and toileting transfers. The MDS noted Resident #71's cognitive skills for daily decision making were intact. Review of the care plan initiated 4/1/22 (revised 10/19/23) documented, The resident is at risk for falls related to gait/balance problems. The goal for Resident #71 was to minimize the risk of falls. The care plan interventions included: be sure the resident's call light is within reach and encourage the resident to use it. Bed in low position. Ensure the resident is wearing appropriate foot ware/non-skid socks when ambulating or mobilizing in w/c(wheelchair). Review of the Fall Incident Reports: Fall #1 occurred on 1/10/24 at 3:00 a.m., documented Resident observed to a sitting position, onto 105507 Page 12 of 24 105507 03/13/2024 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 her buttocks at the foot of the bed, while sleeping sitting on up on the edge of bed. Resident stated I just slipped down. No injuries were observed at the time of the incident. Review of the Post Fall Documentation (12 HR) dated 1/11/24 at 5:25 a.m., documented response to questions: Residents Affected - Some Care plan changes/New interventions No. Fall related injuries, No. Fall interventions in place, Yes. Review of the care plan revealed no new care plan interventions were initiated to prevent Resident #71 from falling. Fall #2 occurred on 2/3/24 at 6:30 a.m., documented Resident observed sitting on the floor of her bathroom. Resident stated I fell asleep and slid off. No injuries observed at the time of incident. Review of the Post Fall Documentation (12 HR) dated 2/5/24 at 6:52 a.m., documented response to questions: Care plan changes/New interventions No. Fall related injuries, No. Fall interventions in place, Yes. Fall #3 occurred on 2/6/24 at 2:00 a.m., documented, Resident found on her side by CNA (certified nursing assistant), after she fell to her knees trying to use walker to walk. Patient states she locked the walker but then fell to her knees. No injuries observed at time of incident. Review of the Post Fall Documentation (12 HR) dated 2/7/24 at 5:13 a.m., documented response to questions: Care plan changes/New interventions No. Fall related injuries, No. Fall interventions in place, Yes. A Fall Risk Evaluation dated 2/6/24 documented a score of 65 indicating a high risk for falls. On 2/6/24 the care plan was updated with the intervention, Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility such as (park activities, music, dancing, movies or nail care). On 3/13/24 at 11:10 a.m., in an interview the Director of Nursing (DON) said she was the acting 105507 Page 13 of 24 105507 03/13/2024 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 - Some Risk Manager for the facility. The DON explained the process for reviewing falls was We do morning clinical and we look at the falls and the 24 hour report sheet, the risk management piece. Any new orders we review and someone from the Therapy Department does attend. The process is to review the incident report in morning clinical. We have a Registered Nurse Practitioner who attends our meeting Mondays to Fridays, and she will see the resident after a fall. During the meeting we make sure notifications have been completed with the family and the physician. We review any injuries. An interdisciplinary note is written, and we review what interventions are needed and add them to the care plan. The DON said the root cause of fall number one on 1/10/24 was, I don't know. I have not completed a root cause analysis. The DON said, I do not have a root cause analysis for any of Resident #19's 3 falls because I did not do that. The DON confirmed the care plan was not consistently updated after each fall and confirmed she did not have any interdisciplinary notes after Resident #19's falls. The DON said we review the falls in Quality Assurance Plan Improvement(QAPI). We review the total number over the month and the shift and figure out if they are at a particular time of day if the Pt has multiple falls. A request to review the QAPI minutes for falls and the DON said we have reviewed them in QA yet, because we have not had our meeting for this month. The DON said she was aware Resident #19's falls occurred during the night on the way to use the bathroom and said the resident was not on a bowel and bladder program. On 3/13/24 at 11:24 a.m., in an interview Resident #19 said, I fall because I have to go to the bathroom. When I have to go, I have to get there right away. I don't always use my call light because I like to do it myself. I seem to fall asleep on the toilet or sitting on the edge of the bed. I don't know why I'm so sleepy but sometimes I fall asleep when I'm trying to get up and go to the bathroom. The last fall I had my knees buckled and gave out and I fell. I think I forgot to lock the brakes on the walker because I was going to get something on my way to the bathroom. I wish I could tell you that I'll use the call light, but I probably won't. 2. The facility policy S-406, Smoking - Supervised, effective 11/30/14 (revised 2/7/20) documented The Center will provide a safe, designated smoking area for residents. For the safety of all residents the designated smoking area will be monitored by a staff member during authorized smoking times. The Center will retain and store matches, lighters, etc., for all residents. On 3/10/24 at 11:10 a.m., in an interview with Licensed Practical Nurse (LPN) Staff W said the residents were allowed to keep the cigarettes in their rooms but not the lighters. The smoking aide was responsible to light the cigarettes. Review of the clinical record revealed Resident #71 had an admission date of 2/8/23 with diagnoses including Chronic obstructive pulmonay disease and nicotine dependence. The clinical record contained a Smoking Evaluation form dated 3/10/24 at 6:23 p.m., identified Resident #71 was determined to be a safe smoker requiring constant supervision while smoking. On 3/10/24 at 11:28 a.m., during an interview and observation, Resident #71 was sitting in his room in a wheelchair. He had a pack of cigarettes on his nightstand and said he had just come in from 105507 Page 14 of 24 105507 03/13/2024 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 - Some smoking. When asked if he had a lighter, he said yes it in the top drawer right there. Resident #71 opened the top nightstand drawer to show he had a green lighter. He said, no one ever told me I couldn't have it. Photographic evidence obtained. On 3/10/24 at 11:34 a.m., the Director of Nursing (DON), the Regional Nurse Consultant and Unit Manager Staff B were notified of Resident #71 having a lighter and cigarettes in his room. The Unit Manager went to the room and retrieved the lighter. The DON said the residents were able to have cigarettes in the room but no lighters. On 3/12/24 at 10:15 a.m., in an interview with Activity Assistant Staff C she said during the day she or the other activity person will be out in the smoking area to monitor the residents. We do not search them for lighters. When they come inside, we check them to make sure they are not hiding any lit cigarettes and they do not have any burn holes in their clothing. We have the lighter and we light the cigarette. At admission they review the smoking policy and ask if they have a lighter to please turn it over. There are metal ashtrays on the tables for the residents and if they need to be emptied, we empty them into the red, metal buckets with the lids. Staff C revealed the lighters are kept in a locked treatment cart on the smoking patio. She said once they leave for the day, a CNA is assigned to the smoking area. On 3/13/24 at 1:02 p.m., in an interview the DON, she said there were currently 25 residents in house who smoke. 105507 Page 15 of 24 105507 03/13/2024 Aviata at North Fort Myers 991 Pondella Rd N FT Myers, FL 33903

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, review of facility policy and procedure, review of the clinical record and staff interview, the facility failed to follow their policy and procedure and physician orders for the use of oxygen for 1 (Resident #273) of 1 resident reviewed for oxygen use. The facility failed to have a system in place to ensure the oxygen concentrator filters were removed and cleaned per the manufacturers recommendation. The facility had 19 residents with oxygen concentrators. Residents Affected - Few The findings included: The facility policy N-1440 Oxygen effective 11/30/14 (revised 8/23/17) documented, Obtain Physician's order. Set flow at level ordered by the physician. Review of the manufacturers recommendation for the oxygen concentrator Cleaning the Cabinet Filter, specified Risk of danger. To avoid damage to the internal components of the unit, do not operate the concentrator without the filter installed or with a dirty filter . Remove the filter and clean as needed. On 3/10/24 at 9:55 a.m., Resident #273 was observed in bed, there was an oxygen concentrator in her room that was turned on and set on 3.5 liters per minute (LPM). The nasal cannula (NC) was on the floor. The concentrator filter was observed to have a thick layer of brown dust and debris. Photographic evidence obtained. On 3/10/24 at 10:00 a.m., in an interview Certified Nursing Assistant Staff O said, only the nurse touches the concentrator. I do not touch the dial; I will put the tube in her nose but that is all. On 3/10/24 at 2:18 p.m., Resident #273 was observed in bed, the oxygen tubing was on the floor and the concentrator was set at 4.5 LPM. On 3/10/24 at 2:21 p.m., a review of the clinical record revealed Resident #273 did not have a physician order for the use of the oxygen. On 3/11/24 at 8:49 a.m., Resident #273 was observed with the oxygen concentrator on and set at 3.5 liters. Resident #273 said she was often short of breath. On 3/11/24 at 1:15 p.m., the Director of Nursing provided a copy of a physician order dated 3/11/24 for oxygen at 3 Liters per minute via a nasal cannula. On 3/12/24 at 8:50 a.m., in an interview the Regional Nurse Consultant said the nurses and housekeeping would be responsible for cleaning the oxygen concentrators. When asked if the housekeeping staff had training in cleaning the concentrator filters, she replied no, that would be nursing. On 3/12/24 at 9:01 a.m., in an interview Licensed Practical Nurse (LPN) Staff H said nurses are responsible to change the tubing and ensure it is in a plastic bag when not in use. I have that room for rounds, we check to make sure the room is clean, the concentrator tubing has been changed. To be honest I have never thought about checking the filters. We will make sure we do rounds on all the 105507 Page 16 of 24 105507 03/13/2024 Aviata at North Fort Myers 991 Pondella Rd N FT Myers, FL 33903

F 0695 machines; they are working on it now. Level of Harm - Minimal harm or potential for actual harm On 3/12/24 at 9:09 a.m., in an interview LPN Staff A said any nurse can obtain an order for oxygen. It is universal that we can start oxygen on anyone who needs it at 2 LPM and then obtain a physician order. The process for cleaning the concentrator is once it is discontinued the nurse or the CNA takes it to the soiled utility room and then housekeeping cleans it and puts it in the clean utility room. The 7:00 p.m., to 7:00 a.m., nurse is responsible to change the oxygen tubing. I don't know about the filters; I know the Unit Manager and the Assistant Director of Nursing (ADON) are working on that now. I don't know why the resident did not have an order she uses it every day. Residents Affected - Few On 3/12/24 at 9:15 a.m., in an interview the Assistant Director of Nursing (ADON) said she was aware of the concern with Resident #273's oxygen concentrator filters and cleaning them. She said we are working on that now. On 3/12/24 at 9:35 a.m., in an interview Housekeeping Staff R said once a concentrator is no longer in use, we clean the outside of the concentrator and put a plastic bag over it and move it to the clean utility room. We do not clean the filters, nursing does that, we don't touch the filters. On 3/12/24 at 12:57 p.m., the DON provided a copy of Resident #273's Treatment Administration Record, it confirmed the oxygen was not ordered until 3/11/24. The DON said she did not know why Resident #273 did not have an order for the oxygen used daily since admission. On 3/13/24 at 10:29 a.m., in an interview the DON she said she did know why the oxygen was not ordered when initiated for Resident #273. She said the oxygen concentrators were the facilities equipment but she did not know who was responsible to clean the filters. She said we are working on it now to get a program in place. She said she did not know who was responsible to fix the concentrators should a repair be necessary. 105507 Page 17 of 24 105507 03/13/2024 Aviata at North Fort Myers 991 Pondella Rd N FT Myers, FL 33903

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review the facility failed to maintain ongoing, effective communication with dialysis centers and failed to ensure 2 (Residents #176 and #63) of 2 sampled residents receiving dialysis received appropriate care and services before and after dialysis treatments. The facility failed to have documentation of an agreement with the dialysis centers providing treatment to Residents #176 and #63. Residents Affected - Some The findings included: The facility policy N-1359, Coordination of Hemodialysis Services effective 11/30/14 and last revised 7/2/19 reads, Residents requiring an outside ESRD [end stage renal dialysis] facility will have services coordinated by the facility. There will be communication between the facility and the ESRD facility regarding the resident. The facility will establish a Dialysis Agreement/Arrangement if there are any residents requiring Dialysis Services. The agreement shall include how the residents care is to be managed. Procedure: 1. The Dialysis communication form will be initiated by the facility for any resident going to an ESRD center for hemodialysis. 2. Nursing will collect and complete the information regarding the resident to send to the ESRD Center . 4. Upon the resident's return to the facility, nursing will review the Dialysis Communication form and information completed by the dialysis center . 5. Nursing will complete the post dialysis information on the dialysis communication form and file the completed form in the Resident's Clinical record. Review of the clinical record revealed Resident #176 was admitted to the facility on [DATE] with a diagnosis of end stage renal disease. Resident #176 had a shunt (access site for dialysis treatment) in her left arm. Resident #176 had physician's orders to receive Dialysis at Dialysis Center A on Mondays, Wednesdays, and Fridays each week. On 3/12/24 Review of Resident #176's Dialysis treatment book showed two forms titled Dialysis Communication Record. The Dialysis Communication Record dated 3/11/24 was left blank as to the name phone and fax of Company A Dialysis facility. The Transport Company was also blank on the form. The location of the shunt site was blank. The time the resident left for dialysis was documented as AM. There was no documentation of an assessment of Resident #176 upon returning from Dialysis on 3/11/24. The Dialysis Communication Form dated 3/6/24 had a documented set of vital signs prior to dialysis 105507 Page 18 of 24 105507 03/13/2024 Aviata at North Fort Myers 991 Pondella Rd N FT Myers, FL 33903

F 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some but the other information required on the form was blank The time the resident left for dialysis was documented as AM. There was no documented assessment of Resident #176 when she returned from dialysis on 3/6/24. The facility provided two additional Dialysis Communication forms dated 2/26/24 and 2/21/24. The form dated 2/26/24 did not have the resident's name, and noted the dialysis access site (shunt) was located in the right hand. There was no post dialysis assessment documented on the forms. Review of the electronic documentation of vital signs in the resident's medical record showed no documented vital signs on 2/21/24 or 2/26/24. On 3/12/24 at 9:30 a.m., Resident #176 was observed lying in bed. An AV (arteriovenous) shunt was observed in Resident #176's left antecubital area. A pressure dressing was observed above the antecubital area. When asked how long the dialysis unit tells her to keep the dressing on her arm, Resident #176 said six hours. On 3/12/24 at 10:00 a.m., Licensed Practical Nurse, Staff A (Resident #176's assigned nurse) said she could not answer any question regarding Resident 176's assessments after her dialysis because she was never working on the days Resident #176 was scheduled for dialysis. On 3/12/24 at 10:03 a.m., Licensed Practical Nurse Staff O verified nursing staff had not completed the Dialysis Communication Forms and were not documenting a pre-treatment and post-treatment assessment of the resident. On 3/12/24 at 10:05 a.m., Licensed Practical Nurse, Unit Manager, Staff B verified there was missing documentation for Resident #176's Dialysis Communication forms. She stated she had attempted to contact the Dialysis Unit and she got a hold of a person at the dialysis facility company A who told her the facility was closed on Tuesdays. On 3/12/24 at 10:30 a.m., the Director of Nursing (DON) verified there was only two communication forms in the resident's dialysis folder and the two forms were missing information. The DON said she was told Resident #176's communication forms were being left at the dialysis facility. The DON said she did not know if the facility had a agreement with dialysis Company A. She stated the Administrator was working on it. The DON did not know how long the dressing from the access site should remain in place after dialysis treatment per the dialysis center policy. The DON verified the importance of removing the pressure dressing per the facilities policy to prevent the shunt (access site) from clotting. The DON verified the importance of a post dialysis assessment when Residents returned from dialysis to ensure their blood pressure was stable after receiving hemodialysis. On 3/13/24 at 2:00 p.m., the Administrator verified the facility did not have an agreement with dialysis center A who provided dialysis treatment to resident #176. Review of the clinical record revealed Resident #63 was readmitted to the facility on [DATE]. Diagnoses included End Stage Renal Disease. 105507 Page 19 of 24 105507 03/13/2024 Aviata at North Fort Myers 991 Pondella Rd N FT Myers, FL 33903

F 0698 Level of Harm - Minimal harm or potential for actual harm Resident #63's physician's order dated 8/3/23 was to receive Hemodialysis at dialysis center B at 11:00 a.m., on Mondays, Wednesdays, and Fridays. On 3/12/24 at 10:30 a.m., a request was made to the DON for the previous two months of completed dialysis communication forms for Resident #63. Residents Affected - Some On 3/12/24 at 12:00 p.m., seven Dialysis Communication Forms were reviewed. The form dated 2/12/24 had no vital signs documented pre or post dialysis treatment. Four of the seven forms had no post dialysis assessment documented. The Dialysis Communication Form dated 2/19/24 documented Resident #63 had a shunt in her left arm. when Resident #63 had a Catheter in her chest for access on 2/19/24. The facility should have documented at a minimum sixteen Dialysis Communication Forms from the time Resident #63 had been readmitted on [DATE]. There was no documentation provided by the facility Resident #63 had received the appropriate number of dialysis treatments from 2/3/24 to 3/13/24. On 3/13/24 at 2:00 p.m., the Administrator said the facility did not have an agreement with dialysis center B where Resident #63 received dialysis treatments. 105507 Page 20 of 24 105507 03/13/2024 Aviata at North Fort Myers 991 Pondella Rd N FT Myers, FL 33903

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interview the facility policy the facility failed to ensure nursing staff were competent to provide care and services to 2 (Residents #176 and #63) of 2 sampled residents receiving dialysis. The findings included: The facility policy N-1359, Coordination of Hemodialysis Services effective 11/30/14 and last revised 7/2/19 reads, Procedure: 1. The Dialysis communication form will be initiated by the facility for any resident going to an ESRD center for hemodialysis. 2. Nursing will collect and complete the information regarding the resident to send to the ESRD Center . 4. Upon the resident's return to the facility, nursing will review the Dialysis Communication form and information completed by the dialysis center . 5. Nursing will complete the post dialysis information on the dialysis communication form and file the completed form in the Resident's Clinical record. 1. Review of the clinical record revealed Resident #176 was admitted to the facility on [DATE] with a diagnosis of end stage renal disease. Resident #176 had a shunt (access site for dialysis treatment) in her left arm. The physician's orders included dialysis treatments at a local dialysis center on Mondays, Wednesdays, and Fridays. Review of the resident's dialysis binder where the facility keeps the communication forms used to document coordination between the facility and the dialysis center revealed the Dialysis Communication Record dated 3/11/24 the location of the shunt site was blank. There was no documentation of an assessment of Resident #176 upon returning from Dialysis on 3/11/24. The Dialysis Communication Form dated 3/6/24 had a documented set of vital signs prior to dialysis. There was no documented assessment of Resident #176 when she returned from dialysis on 3/6/24. The facility provided two additional Dialysis Communication forms dated 2/26/24 and 2/21/24. The form dated 2/26/24 noted the dialysis access site (shunt) was located in the right hand. There was no post dialysis assessment documented on the forms. Review of the electronic documentation of vital signs in the resident's medical record showed no documented vital signs on 2/21/24 or 2/26/24. 2. Review of the clinical record revealed Resident #63 was readmitted to the facility on [DATE]. 105507 Page 21 of 24 105507 03/13/2024 Aviata at North Fort Myers 991 Pondella Rd N FT Myers, FL 33903

F 0726 Diagnoses included End Stage Renal Disease. Level of Harm - Minimal harm or potential for actual harm Resident #63's physician's order dated 8/3/23 was to receive Hemodialysis at dialysis center B at 11:00 a.m., on Mondays, Wednesdays, and Fridays. Residents Affected - Some On 3/12/24 at 10:30 a.m., a request was made to the DON for the previous two months of completed dialysis communication forms for Resident #63. On 3/12/24 at 12:00 p.m., seven Dialysis Communication Forms were reviewed. The form dated 2/12/24 had no vital signs documented pre or post dialysis treatment. Four of the seven forms had no post dialysis assessment documented. The Dialysis Communication Form dated 2/19/24 documented Resident #63 had a shunt in her left arm when Resident #63 had a Catheter in her chest for access on 2/19/24. On 3/13/24 at 10:00 a.m., in an interview Registered Nurse, Staff F said she had been regularly assigned to provide nursing care to Resident #63. Staff F said she was not aware Resident #63 had a chest catheter for dialysis access at that time. Staff F said she had worked at the facility since July of 2023 and had not received any training or competencies regarding pre and post assessments of residents receiving dialysis. On 3/13/24 at 10:10 a.m., in an interview Licensed Practical Nurse, Unit Manager Staff B said she had not received any in-services or competencies regarding caring for residents receiving dialysis. Staff B's date of hire at the facility was on 5/16/2023. On 3/13/24 at 10:25 a.m., in an interview Registered Nurse Staff K said she had never received any in-services or competencies on caring for a resident receiving dialysis treatments since she had started working at the facility. Staff K's date of hire was 7/21/20. On 3/13/23 The Director of Nursing stated she was not able to provide any documentation the licensed nurses were trained in the facility policy for assessing dialysis patients both pre and post dialysis treatments and in communication with dialysis units providing care to residents receiving dialysis at the facility. 105507 Page 22 of 24 105507 03/13/2024 Aviata at North Fort Myers 991 Pondella Rd N FT Myers, FL 33903

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility policies and procedures, and resident and staff interviews, the facility failed to maintain an effective pest control program and a sanitary environment free from pests for 3 (Residents #23, #51 and #49) of 26 sampled residents. Residents Affected - Few The findings included: The facility policy HL-200 Pest Control, effective 11/30/14 documented The facility will maintain a pest control program which includes inspection, reporting and prevention. Any unusual occurrence or sighting of insects should be reported to the Supervisor. Proper action will be taken. On 3/10/24 at 9:28 a.m., during an observation of Resident #49's bathroom one live small brown crawling insect was noted in the bathroom sink. There was a wash basin on the floor under the sink with two larger brown insects on their back with legs in the air, not moving. There was a live brown insect making a web from the sink to the wash basin. There were several small dead brown insects in the wash basin. 3/10/24 at 9:29 a.m., Central Supply Staff D entered the room and verified the observation of the dead and live insects in Resident #49's bathroom. She said she would notify someone of the bugs. On 3/10/24 at 12:00 p.m., a second observation of Resident #49's bathroom revealed five live medium brown insects crawling from the sink. On 3/10/24 at 12:21 p.m., observation of Resident #49's bathroom with the Administrator revealed a medium brown live insect crawling on the sink. On 3/11/24 at 1:11 p.m., in an interview Resident #49 said all of a sudden, they want to spray in here for roaches. My roommate and I tell them all the time there are bugs in here. They come in from around the air-conditioner and we have flying bugs in here too. I always tell the staff and they have come in here and seen the bugs. It's terrible. Who would want to deal with it every day and it is every day, especially at night. On 3/11/24 at 1:27 p.m., review of the Pest Control Log revealed on 3/10/24 the concern of roaches and spiders in the bathroom of Resident #49's room. The log showed on 2/21/24 a report of roaches in the dresser drawers of Resident #49 and her roommate. The log showed form 11/20/23 to 3/10/24, roaches were reported in several areas of the facility. Review the Exterminators Report dated 3/12/24 documented no pest activity noted in Resident #49's room. On 2/27/24 the Exterminators Report documented no pest activity in Resident #49's room. On 1/9/24 the Exterminators Report documented no pest activity in the facility. On 3/12/24 at 3:45 p.m., in an interview Registered Nurse Staff F said I have not seen roaches in here but the residents have complained that at night they come out. The residents see them and I put 105507 Page 23 of 24 105507 03/13/2024 Aviata at North Fort Myers 991 Pondella Rd N FT Myers, FL 33903

F 0925 it in the exterminator log book at the nurse desk. Level of Harm - Minimal harm or potential for actual harm On 3/12/24 at 3:49 p.m., in an interview Certified Nursing Assistant Staff G said she sees roaches sometimes when you turn the light on in residents rooms throughout the facility and said she reports it to the nurse. Residents Affected - Few On 3/13/24 at 11:30 a.m., in an interview Resident #51 said, I have seen a big roach right there in the corner by the bathroom once at night. I don't think I have seen any other bugs here. I told the girl about it. On 3/13/24 at 11:36 a.m., in an interview Resident #23 said when I was on the Canterbury Hall I had roaches really bad, it took a while for them to get rid of them. I got moved here on [NAME] Hall I have only seen a small bug once in my room. They come in here and spray for bugs. Sometimes I see the palmetto bugs but this is Florida, they are everywhere. 105507 Page 24 of 24