Health inspection·November 14, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on record review, review of facility's policies and procedures, and staff interviews, the facility failed to time for 1 (Resident #3) of 3 residents' incidents reviewed. The findings included: The facility's Abuse, Neglect, Exploitation & Misappropriation with a revision date of 11/16/2022 noted under reporting/response, Any employee or contracted service provider who witnesses or has knowledge of an act of abuse or an allegation of abuse, neglect . including injuries of unknown source . to a resident, is obligated to report such information immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury . to the Administrator and to other officials in accordance with State law . Once the allegation of abuse is reported, the Executive Director, as the abuse coordinator, is responsible for ensuring that reporting is completed timely and appropriately to appropriate officials in accordance with Federal and State regulations. Review of the clinical record for Resident #3 revealed an Annual Minimum Data Set Assessment with a target date of 8/7/24 which noted the resident's cognition was moderately impaired with a Brief Interview for Mental Status score of 11. Resident #3 range of motion was impaired on one side of the upper extremity and lower extremity. Resident #3 required substantial/maximal assistance to transfer from chair to bed and bed to chair. The resident's care plan initiated on 8/10/21 noted the resident had impaired cognitive function/dementia or impaired thought processes. A nursing progress dated 8/12/24 at 3:55 p.m., noted the resident was lying in bed with moan of pain. When staff asked where it hurt the resident initially touched her abdomen. As they attempted to get her dressed for the day a blue discoloration of approximately 3.0 centimeters (cm) was noted to the right foot, a blue discoloration to the front of the right lower leg approximately 5.0 cm and swelling to the leg and foot. When asked how she sustained the discoloration and pain to the right foot the resident said, the other one. When asked if she fell, she initially said no. When asked again if she fell, she said yes. The nurse noted she notified the Director of Nursing and the Advanced Practice Registered Nurse. On 8/12/24 at 11:50 p.m., a nursing progress note documented an X-ray result of the right lower extremity showed a proximal tibia/fibula (the two long bones in the lower leg) fracture. Resident #3 was sent to the hospital for evaluation and treatment. Page 1 of 5 105507 105507 11/14/2024 Aviata at North Fort Myers 991 Pondella Rd N FT Myers, FL 33903

F 0609 Level of Harm - Minimal harm or potential for actual harm Review of the facility's investigation showed documentation the Director of Nursing and the Administrator were notified of the discoloration and pain to the resident's right lower extremity on 8/12/24 at 3:59 p.m. 11:06 a.m. Residents Affected - Few On 11/13/24 at 8:40 a.m., Resident #3 was observed in bed. Resident #3 said yes when asked if she recalled breaking her leg. When asked if she remember how she sustained the injury, she said no. On 11/14/24 at 12:00 p.m., in an interview the Director of Nursing said the resident was not able to say how she sustained the fracture to her right lower extremity. The Administrator and the Regional Nurse Consultant who were present during in the interview verified the initial reporting of the injury of unknown source should have been made to the Agency for Health Care Administration within two hours of being aware of the incident. 105507 Page 2 of 5 105507 11/14/2024 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 Based on observations, record review, review of facility's policies and procedures, resident and staff interviews, the facility failed to ensure 1 (Resident #2) of 1 resident reviewed for dialysis received care and services to meet her needs. Residents Affected - Some The findings included: The facility's policy and procedure Coordination of Hemodialysis Services with a revision date of 07/02/2019 noted, Residents requiring an outside ESRD (End Stage Renal Disease) facility will have services coordinated by the facility. There will be communication between the facility and the ESRD facility regarding the resident . Procedure: The Dialysis Communication form will be initiated by the facility for any resident going to an ESRD center for hemodialysis. Nursing will collect and complete the information regarding the resident to send to the ESRD Center. The ESRD facility is to review the Dialysis Communication form and either : a. Complete the communication form and return with the resident or b. Provide treatment information to the facility. Upon the resident's return to the facility, nursing will review the Dialysis Communication form and information completed by the dialysis center OR the information sent by the dialysis center; communicate with the resident's physician and other ancillary departments as needed, implement interventions as appropriate. 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 for Resident #2 revealed a re-admission date of 9/21/24. Diagnoses included chronic kidney disease stage 4 (severe) and dependence on renal hemodialysis (procedure that filters blood to remove waste and excess fluid when the kidneys are no longer functioning properly). The physician's orders included: Hemodialysis to a dialysis center on Mondays, Wednesdays and Fridays. The order specified to be sure to send the dialysis binder with the completed hemodialysis communication record. Collect binder on return, complete hemodialysis sheet and send to medical records. Review of the Medication Administration Record (MAR) for October and November 2024 revealed Resident #3 went to the dialysis center hemodialysis on 10/2/24 (Wednesday), 10/4/24 (Friday), 10/11/24 (Friday), 10/14/24 (Monday), 10/16/24 (Wednesday), 10/18/24 (Friday), 11/1/24 (Friday), 11/8/24 (Friday), and 11/11/24 (Monday). No communication forms were found in the clinical record for those dialysis days. On 11/13/24 at 1:38 p.m., a joint interview was conducted with the Director of Nursing (DON) and the Regional Nurse Consultant. The Director of Nursing (DON) verified the lack of documentation the facility coordinated with the dialysis center on 10/2/24,10/4/24, 10/11/24, 10/14/24, 10/16/24, 10/18/24, 11/1/24, 11/8/24 and 11/11/24. She said she's had multiple communications with the dialysis center but did not document her conversations. On 11/13/24 at 2:20 p.m., in a telephone interview a representant of the dialysis center said the facility does not follow up on their concerns. She said the dialysis center has even tried to call 105507 Page 3 of 5 105507 11/14/2024 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 the facility multiple times. They finally spoke with the DON but the dialysis center was still having concerns with fluid overload and the facility not following the renal diet for resident #2. 2. Review of Resident #2's physician's orders revealed a prescribed controlled carbohydrate renal diet. On 11/13/24 at 8:45 a.m., in an interview Resident #2 said she went to the dialysis center on Mondays, Wednesdays, Fridays and sometimes Thursdays and Saturdays. She said the facility gives her a lunch meal on dialysis days that usually consists of a peanut butter sandwich and graham crackers. On 11/13/24 at 10:45 a.m., with the resident's permission the lunch meal provided by the facility was observed. It consisted of a sliced dark pink lunch meat and cheese sandwich, graham crackers, a cup of apple sauce, a cup of pudding and a bottle of water. On 11/13/24 at 1:38 p.m., a joint interview was conducted with the Director of Nursing (DON) and the Regional Nurse Consultant. The DON said Resident #2 was her own person and was not compliant with the controlled carbohydrate and renal diet. She said the resident frequently consumes food that is not within the prescribed diet. She showed a grocery bag containing a bag of popcorn, two candy bars and a can of soda which she said belonged to Resident #2. She said she did not know where the resident obtained the food. On 11/13/24 at 2:20 p.m., in a telephone interview a representant of the dialysis center said today (11/13/24) the facility gave Resident #2 a sandwich with a thick slice of ham and cheese. She said there was too much sodium in the food provided, and Resident #2 had excess fluid. Review of the hemodialysis communication form dated 11/4/24 showed documentation from the dialysis center stating, Pt (patient) needs to comply with strict fluid/sodium restrictions. On 11/13/24 at 2:36 p.m., in a telephone interview the facility's Registered Dietitian (RD) said she consulted with the dialysis center for foods Resident #2 could not have and printed the renal diet for the kitchen. She said regular ham would be high in salt and would not be recommended. She said cheese can be high in phosphorus. She said as far as what they send with Resident #2, they are renal diet compliant. She said she spoke with the dialysis Renal Dietitian monthly or more if there are concerns. She said she has tried to educate Resident #2 but she is not receptive to education at all. Review of the Diet and Nutrition Care Manual used by the facility showed for renal dialysis sodium should be restricted if needed to avoid excess fluid retention and weight gain between dialysis treatments. Phosphorus should be adjusted to maintain serum phosphate levels in the normal range. The bioavailability of phosphorus food sources should be taken into consideration. Normally, phosphate binders are prescribed with meals. The list of high phosphorus foods to limit if indicated included Swiss cheese. On 11/13/24 at 2:45 p.m., in an interview the Dietary Director said Resident #2 was provided with a turkey sandwich and Swiss cheese. She said she did not have the packaging for the turkey used in the sandwich, it was left over turkey. On 11/13/24 at 5:15 p.m., in an interview Resident #2 said she gets her snacks from the activity 105507 Page 4 of 5 105507 11/14/2024 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 department. The resident verified she got the package of popcorn, doughnuts, candy bars and sodas from the activity department. On 11/13/24 at 5:20 p.m., in an interview the Activity Director verified Resident #2 purchases snacks from the activity department. She said the Registered Dietitian gave them a list of each resident's diet so they'll know what snacks they can have. She said her assistant provided the resident with the snacks. Review of the diet list showed Resident #2's diet was listed as CCD (carbohydrate controlled) Renal diet. The Activity Staff said she did not know what a CCD Renal Diet was. On 11/14/24 at 10:30 a.m., the Dietary Director provided a list of Dialysis Lunch Bag Menu Selections. She said the dietary department selects food items from the list to provide a lunch to Resident #2 on dialysis days. The list included turkey sandwich and specified No cheese or Tomato and Peanut Butter sandwich with the Registered Dietitian's approval. The Dietary Director verified Resident #2 gets a peanut butter at times to go to dialysis. She said she did not have the Registered Dietitian's approval for the peanut butter sandwich but she could get it. 3. Review of the Physician's ordered medications revealed an order for Renvela oral tablet 800 milligrams (binds phosphorus from the food to control phosphorus level), one tablet three times daily with meals. Review of the facility's mealtime schedule showed breakfast is from 7:15 a.m., to 8:00 a.m., lunch is from 12:15 p.m., to 1:15 p.m., and dinner is at 5:15 p.m., to 6:00 p.m. The Medication Administration Records (MARs) for October and November 2024 showed the Renvela was administered every day in the morning, in the evening and at HS (bedtime). The MARs lacked documentation the Renvela was administered with the dinner meals. On 11/13/24 at 1:38 p.m., a joint interview was conducted with the Director of Nursing (DON) and the Regional Nurse Consultant. When asked about the administration time of the Renvela with meals, The DON said the Renvela was, liberalized. She (Resident #2) gets it in the morning, in the evening when she comes back from dialysis and at bedtime. The Regional Nurse Consultant said the liberalized medication administration time for HS was between 7:00 p.m., to 10:45 p.m. She reviewed the administration time for the Renvela for October and November 2024 and verified the Renvela was not administered with the dinner meals as ordered. She also verified Resident #2 was provided a lunch meal on dialysis days but the Renvela was not administered with the lunch meal on dialysis days. 105507 Page 5 of 5