Health inspection·August 1, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on interviews and observations, the facility failed to ensure a safe environment, free from potential accidents/hazards for residents in one smoking area out of one smoking area in the facility, Residents Affected - Few Findings included: On 7/30/2024 at 11:05 a.m., an observation and interview were conducted on the smoking patio area of the facility. Two residents were under the smoking gazebo with two family members present. In the center of the gazebo ceiling there were two wooden planks not connected to a foundation beam bowing down onto the smoking patio. Above the table provided for the residents during smoking times were further beams bowing down but appeared to be connected to a foundation beam. There was heavy growth of plant-like substances on numerous beams. The gazebo had three light foundations that were heavy with plant-like substances and one light fixture without a cover. During the observation a visiting family member stated, I'm surprised this whole thing hasn't fallen down already. (Photographic evidence was obtained). On 8/01/2024 at 9:00 a.m., an interview was conducted with the Nursing Home Administrator (NHA) in the smoking area. The NHA stated the gazebo roof had already been addressed. The beams that were hanging during previous observations were cut away as well as another area of beams. The NHA stated the foundation is solid so the roof beams and coverage will be replaced and the light fixtures will be removed. The NHA stated the lawn service provider has been on vacation for two weeks and will return this coming Monday to address the overgrowth of grass. On 8/01/2024 at 2:20 p.m., an observation was made of a drainage area in the center of the gazebo in the smoking area. A metal grate covered the drainage area but an exposed area approximately one to one and one-half inches wide was observed at one end of the grate with an approximate one-inch height. An observation was made of the vertical foundation beams with numerous cracks and splintered wood. (Photographic evidence obtained). A request for facility policy was requested but not obtained during the time of the survey. Page 1 of 20 105549 105549 08/01/2024 Aviata at the Harbor 1410 Dr Martin Luther King Jr St N Safety Harbor, FL 34695

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility 1) failed to ensure oxygen was delivered according to physician orders for one resident (#91) with a tracheostomy tube out of two sampled residents with a tracheostomy tube, and 2) failed to ensure emergency tracheostomy supplies were readily available at the resident's bedside according to standards of practice for two residents (#91 and #83) out of two residents sampled with a tracheostomy tube. Residents Affected - Some Findings included: 1. Review of Resident #91's admission Record revealed she was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of tracheostomy status, dependence on supplemental oxygen, non-traumatic subarachnoid hemorrhage from left middle cerebral artery, chronic respiratory failure with hypoxia, systemic lupus erythematosus, aphasia, and pulmonary fibrosis. An observation was conducted on 07/29/24 at 10:18 AM of Resident #91. She was observed to be in bed, eyes open, nonverbal, with a tracheostomy tube. She was observed to be receiving oxygen via a tracheostomy (trach) collar. The trach collar was connected to an air compressor with a fraction of inspired oxygen (FIO2) dial set to 80%. An observation was conducted on 07/30/24 at 09:54 AM of Resident #91. She was observed to be in bed, eyes open, and nonverbal. She was observed to have a tracheostomy tube in place. She was observed to be receiving oxygen via a trach collar. The trach collar was connected to an air compressor with the FIO2 dial set to 60%. The air compressor was connected to the oxygen concentrator and the oxygen concentrator was set to 4 liters per minute (LPM). Review of Resident #91's physicians orders revealed an order, with a start date of 7/9/24 and no end date, for Respiratory: Oxygen - continuous 2 Liters via trach every shift. A physician's order, with a start date of 7/2/24 and no end date, for Tracheostomy-6 Shiley. A physician order, with a start date of 7/2/24 and no end date, to keep extra trach tube at bedside. Review of Resident #91's Medication Administration Record (MAR) revealed the physician order with a start date of 7/9/24 for Respiratory: Oxygen- continuous 2 liters via trach every shift was signed off as administered every shift from 7/9/24 through 7/29/24. Review of Resident #91's 3008, dated 5/14/24, revealed a primary diagnosis of malfunction of tracheostomy stoma. Section V. Treatment Devices .Mask Type 28% trach collar Oxygen-Liters 5% Trach Size: 6 fr [French] An interview was conducted on 07/30/24 at 01:35 PM with Staff A, Registered Nurse (RN). Staff A said Resident #91 has a Shiley Tracheostomy tube, size 6. She reviewed the physicians order and said 105549 Page 2 of 20 105549 08/01/2024 Aviata at the Harbor 1410 Dr Martin Luther King Jr St N Safety Harbor, FL 34695

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #91 was supposed to be on two liters per minute (LPM) of oxygen via trach collar. She entered the resident's room, confirmed the resident was on five LPM of oxygen. She said she was a little familiar with the FIO2 settings on the air compressor and said Resident #91 should be on 60 or 75% FIO2 but that is not on our MAR, she observed the FIO2 and confirmed Resident #91 was on 60% FIO2. She reviewed Resident #91's medical record and confirmed there was no physician order related to the FIO2 and said she could only find hospital documentation from 5/14/24, when the resident was first admitted that she was supposed to be on five liters of oxygen with 28% FIO2 but she [Resident #91] had gone out to the hospital since then so I'm not sure what she is supposed to have. Staff A, RN said the resident should have an ambu ( bag (bag valve mask), oxygen tank, suction machine, suction supplies, trach ties, trach cleaning kit, and a Shiley size 6 trach at the bedside with extra size 6 inner cannulas as the emergency tracheostomy supplies. Staff A, RN said she did not think there needed to be a smaller trach size at the bedside. While she was in the residents room, she confirmed there was not a size smaller tracheostomy at the bedside and she confirmed the emergency oxygen tank at the bedside was empty. An interview was conducted on 07/30/24 at 01:49 PM with Staff B, Licensed Practical Nurse (LPN), [NAME] Unit Manager, she said residents with tracheostomy's should have a suction set-up, sterile water, extra inner cannulas, an entire tracheostomy the same size as the resident has, an extra trach collar, full portable oxygen tank, and she said she was not sure if there should be an ambu bag at the bedside and she said she did not think there needed to be a smaller tracheostomy size at the bedside. Review of Resident #91's care plans revealed a care plan, with a revision date of 6/10/24, read: [Resident #91] has a tracheostomy r/t [related to] impaired breathing mechanics. The goal revealed [Resident #91] will have minimal s/sx [signs and symptoms] of infection through the review date. The interventions included Ensure that trach ties are secured at all times. Monitor/document for restlessness, confusion, increased heart rate (Tachycardia), and bradycardia. Monitor/document level of consciousness, mental status, and lethargy PRN [as needed]. Suction as necessary. An interview was conducted on 07/31/24 at 09:18 AM with the Director of Nursing (DON). She said Resident #91 came to the facility with a tracheostomy. She said her tracheostomy frequently plugs with mucus and the resident's oxygen levels frequently drop below normal. She said the resident should be on two LPM of oxygen and she said she called the Respiratory Therapist to clarify the FIO2 setting and she said they do not need to have a physician's order for that setting but, I did go ahead and put that in the chart. The DON said the facility does not have a policy on emergency tracheostomy supplies that should be at the bedside but best practice, We make sure we have a whole change out tracheostomy kit at bedside and we did implement oxygen tanks at the bedside, and they should be full. She stated ambu bags are not necessary at the bedside because they are on the crash carts. She stated, We just keep the size of the trach [tracheostomy] at the bedside. An interview was conducted with the DON on 07/31/24 at 11:29 AM. She said Resident #91's oxygen concentrator was supposed to be set on 2 LPM and the oxygen connects to the 50 psi air compressor, and the air compressor has the FIO2 dial connected to it and the trach collar. She said the FIO2 dial should be set to 80% according to the manufacturer guidelines of the air compressor. Review of the facility's High Humidity Set-ups Utilizing Concentrator with Air Compressor 105549 Page 3 of 20 105549 08/01/2024 Aviata at the Harbor 1410 Dr Martin Luther King Jr St N Safety Harbor, FL 34695

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some guideline, undated, revealed O2 [oxygen] concentrator provides oxygen only. 50 psi Medium Volume Compressor provides aerosol only. Match the pointer with the notch on jet nebulizer dial at 80%. According to the National Library of Medicine (NIH), Tracheostomy Care and Suctioning, dated 2021, When caring for a patient with a tracheostomy tube in the acute care setting, it is important to ensure that proper safety equipment is present at the patient's bedside. there should be spare tracheostomy tubes (same size and one size smaller), lubricant, syringe for cuff inflation, and tracheostomy ties (or means to resecure the tracheostomy tube) if reinsertion is required. A bag valve mask should always be kept at the bedside. https://www.ncbi.nlm.nih.gov/books/NBK593189/ (Photographic evidence obtained). 2. On 7/31/2024 at 9:50 a.m., during medication administration for Resident #83 with Staff J, Licensed Practical Nurse (LPN), an observation was made of tracheostomy emergency supplies for the resident. Staff J, LPN stated there were supplies in the resident bedside table. Upon observation of each drawer, a bag-valve device (ambu bag), oxygen, or a tracheostomy device one size smaller were not present in the room easily accessible for an emergency. On 7/31/2024 at 3:10 p.m., an observation and interview was conducted with Staff J, LPN and the DON regarding emergency tracheostomy supplies available in the room for Resident #83. The DON stated an ambu bag and oxygen are available on the code carts in the hallway at each wing of the facility for emergencies. An observation was made of Staff J, LPN unable to open code cart to demonstrate the location of the ambu bag. The DON opened the code cart to demonstrate the location of the ambu bag and stated an oxygen tank was on the side of the code cart. On 8/01/2024 at 9:30 a.m., an interview was conducted with the Supply Coordinator in the facility's supply room. The Supply Coordinator stated supplies can easily be provided if notified in advance. An observation was made of four ambu bags in separate plastic bags, numerous size 6 and 8 tracheostomy appliances, and one size 4 tracheostomy appliance. The Supply Coordinator could not locate any sizes of tracheostomy appliance kits between 4 and 6 or between 6 to 8 readily available. The Supply Coordinator stated the supply room is locked at night but the nursing supervisor has a key to access the supply room. A record review of Resident #83 admission Record had an original admit date of 10/25/2023 with a readmission date of 11/19/2023. Resident #83 had a primary diagnosis of aphasia following cerebral infarction and secondary diagnoses include but are not limited to dysphagia unspecified, encounter for attention to tracheostomy and gastrostomy. A review of the physician orders, dated 10/26/2023, shows orders to keep extra trach tube at bedside and tracheostomy size 6. A review of Resident #83 care plan, dated 7/25/2024, shows a focus area of tracheostomy related to stroke-cardiac arrest initiated on 11/08/2023. The goal for this focus is to have clear and equal breath sounds bilaterally and to minimize the risk of abnormal drainage around the trach site through the review date. Interventions include but are not limited to ensure trach ties are secured at all times, respiratory therapy to work with capping, and suction as needed. A review of the Minimal Date Set, dated 4/25/2024, Section O-Special Treatments, Procedures and Programs shows in section E1- Tracheostomy care as checked for Resident #83. 105549 Page 4 of 20 105549 08/01/2024 Aviata at the Harbor 1410 Dr Martin Luther King Jr St N Safety Harbor, FL 34695

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review, the facility failed to ensure the medication error rate was less than 5.00%. Thirty-five medication administration opportunities were observed and four errors were identified for one resident (#83) out of four residents observed. These errors constituted an 11.43% medication error rate. Residents Affected - Few Findings include: On 7/31/2024 at 9:50 a.m., medication administration observations were made with Staff J, Licensed Practical Nurse (LPN) for Resident # 83. The staff member dispensed the following medications: - MiraLAX powder 17 grams -Tizanidine 4 milligram (mg) one tablet -Ipratropium Bromide 0.5 mg and Albuterol sulfate 3 mg (resident's representative refused) -Modafinil 200 mg (100 mg) two tablets -Lyrica 100 mg one tablet -Aspirin 81 mg chewable -Eliquis 5 mg one tablet -Guaifenesin oral 200mg/5 milliliters (ml) give 5 ml -gave 5ml of 200mg/10ml -Multivitamin one tablet -Levetiracetam oral solution 100 mg/ml, 10 ml measured A review of the physician orders for Resident #83 has an order. dated 11/21/2023. for B12 Active oral tablet chewable 1 mg (Methyl cobalamin) to give one tablet via Gastrostomy tube (G-tube) one time a day for vitamin. Staff J, LPN stated the medication was not available in the medication cart. Staff J, LPN stated a request was made for a refill through the facility's electronic charting to the pharmacy on 7/17/2024 but a new request will be placed today as well. Staff J, LPN could not state if the medication was not available prior to today's unavailability. A physician order, dated 10/27/2023, for Lansoprazole oral suspension 3mg/ml to give 3mg/ml via G-tube one a day for Gastro-Esophageal reflux disease (GERD). Staff J, LPN stated the medication was not available in the medication cart. Staff J, LPN, stated a request will be placed to pharmacy today for a refill and could not state if the medication was not available prior to today's unavailability. A physician order, dated 10/26/2023, for Metoprolol Tartrate oral tablet 50 mg to give one tablet via G-tube twice a day for hypertension. Staff J, LPN stated the medication was not available in the medication cart and will look in the medication room to see if medication may be in the overstock bins. Staff J, LPN, returned without the medication and stated a request will be made to pharmacy to refill as soon as possible and could not state if the medication was not available prior to today's unavailability. A physician order, dated 10/26/2023, for Guaifenesin oral liquid 200 mg/5ml to give 5 ml via G-tube four times a day for cough/congestion. Staff J, LPN, pulled a bottle of Guaifenesin labeled with Resident #83's name 105549 Page 5 of 20 105549 08/01/2024 Aviata at the Harbor 1410 Dr Martin Luther King Jr St N Safety Harbor, FL 34695

F 0759 and the following label: Guaifenesin 200mg/10ml. Staff J stated, the order says 5 ml so I will give 5 ml. Level of Harm - Minimal harm or potential for actual harm On 8/01/2024 at 11:05 a.m., a telephone interview was conducted with the facility's pharmacist. The pharmacy supplier will see the request when nurses request for a medication refill but the pharmacist to the facility does not have the information only the supplier. The pharmacist will contact the pharmacy supplier to inquire about previous requests made for missing medications for this resident. Residents Affected - Few On 8/01/2024 at 11:27 a.m., an interview was conducted with the Director of Nursing (DON), present were the Regional Nurse Consultant and Regional Social Services Consultant. The DON was made aware of the medication error rate of 11.43% and the missing medication concerns. On 8/01/2024 at 9:30 a.m., an interview was conducted with Staff K, LPN. Staff K was assigned to dispense medication for Resident #83. In the medication cart, Metoprolol was available but B12 and Lansoprazole oral suspension 3mg/ml were not available. Staff K stated B12 should come from central supply and could not state why Lansoprazole was missing for day two. The Supply Coordinator was in hallway at time of discussion and stated B12 one milligram is not something central supply has and must be obtained from pharmacy through a prescription, stating, I have all doses of B12 in my supply but this is a prescription. On 8/02/2024 at 2:28 p.m., an email was received from the facility's pharmacy regarding the pharmacy supplier tracking history for Resident #83's request to dispense medication timeline. [photographic evidence obtained] According to the pharmacy supplier Metoprolol 50 mg was delivered on 8/01/2024 with a 10 quantity and last delivery was on 7/17/2024 with a 10 quantity. Lansoprazole was delivered on 7/18/2024 with a thirty-day supply. According to the pharmacist, B12 of all strengths is on the facility's supply list and 1mg is available to order. A review of the facility's policies and procedures titled: Administering Medications revised April of 2019. The policy statement states medications are administered in a safe and timely manner, and as prescribed. . 4. Medications are administered in accordance with prescriber orders, including any required time frame. 6. Medications errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training. 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. A review of the facility's policies and procedures titled: 1.0 Medication Shortages/Unavailable Medications shows a policy statement: When medications are not received or are unavailable for the customers, the licensed nurse will urgently initiate action in cooperation with the attending physician and the pharmacy provider. 105549 Page 6 of 20 105549 08/01/2024 Aviata at the Harbor 1410 Dr Martin Luther King Jr St N Safety Harbor, FL 34695

F 0759 A. Level of Harm - Minimal harm or potential for actual harm If a medication shortage is noted at the time of medication administration (Med- Pass), the licensed nurse or certified medication assistant must immediately initiate action to obtain the medication and not wait until the Med pass is completed. Residents Affected - Few B. If a medication shortage is noted during normal pharmacy hours: 1. A licensed nurse notifies the pharmacy and speaks to a registered pharmacist to determine the status of the order. Facility link may also be utilized to order or reorder medications and or determine the status of a new or reordered medication. If not ordered, place the order or reorder to be sent with the next scheduled delivery. 2. If the next available delivery results in a delay or missed dose in the customer's medication schedule, take the medication from the emergency stock supply to administer the dose. If ordered medication is not available in the emergency stock, notify the pharmacist that an emergency delivery is required. 3. If medication from emergency stock is utilized- ensure that the pharmacy received the fax information (i.e. customer name, drug, dose) for replacement and appropriate billing. . D. If an emergency delivery is not feasible, a licensed nurse contacts the attending physician to obtain orders or directions which may include: 1. Holding the dose or doses. 2. Use of an alternative medication available from the emergency stock supply. 3. Change in order time of administration or medication. E. 105549 Page 7 of 20 105549 08/01/2024 Aviata at the Harbor 1410 Dr Martin Luther King Jr St N Safety Harbor, FL 34695

F 0759 Level of Harm - Minimal harm or potential for actual harm If the medication is unavailable and cannot be supplied from the manufacturer, a registered pharmacist informs the licensed nurse and attending physician of the expected date of availability and or a therapeutically equivalent alternative medication. 1. Residents Affected - Few Obtain alternate physician orders, as necessary. Orders may include: a. holding the dose or doses until the medication is available b. use of an alternative medication. 2. If unavailable to obtain a response from the attending physician in a timely manner, notify nursing supervisor and contact the medical director for orders or direction. a. Explain the circumstances of the drug product shortages to obtain an appropriate order. 105549 Page 8 of 20 105549 08/01/2024 Aviata at the Harbor 1410 Dr Martin Luther King Jr St N Safety Harbor, FL 34695

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. Based on observations, interviews, and record review the facility did not ensure medication was stored safely for one out two medication rooms, two out of three medication carts, one treatment out of two treatment carts and medication properly stored for one resident (#38) out of forty residents sampled. Findings include: On July 29, 2024, at 10:00 a.m., during the initial tour of the east wing an inhaler was observed on Resident 38's bedside table [photograph evidence obtained]. Upon this observation the resident was not in the room to interview. Further observation revealed the inhaler present on the bedside table later during the afternoon. On July 30, 2024, at 8:25 a.m., an observation was made on the east wing of an unlocked treatment cart. The cart was located across from the nurses' station in an area where residents could easily open drawers. In the second drawer were various residents medications for wound care. Staff J, Licensed Practical Nurse (LPN) locked the drawer and stated the drawer was most likely re-stocked last night or early this morning and they forgot to lock the drawer. On July 30, 2024, at 2:00 p.m., an observation was made of the west wing medication room. The floors were grossly contaminated with dried stained rusty brown liquid. The sink was grossly contaminated with brown liquid and fragments of medication needle cap and a medication vial cap. A temperature log outside of the medication refrigerator was documented as complete for all the days of July with temperatures in the thirty Fahrenheit range (30-37). The current temperature for this refrigerator was 52-54 degrees Fahrenheit. Inside the refrigerator hanging from the top was a large solid piece of ice. Staff B, LPN/Unit Manager (UM) and an unnamed nurse agreed to the refrigerator temperature of 52-54 range and verified the large solid piece of conformed ice hanging from inside the top part of the refrigerator. Inside the refrigerator was a small hard plastic box with two red zip ties. Staff B, LPN/UM stated the box was the facility's emergency box (ebox) and the red zip ties indicate to staff and pharmacy the box has been opened and needs replacement. Staff B stated the box was opened yesterday to obtain insulin. An observation was made of a shelf in the medication room of a sticky substance under a medication box [photographic evidence obtained]. When lifting the box, the medication box left remnants of the box on the shelf. Staff B witnessed the sticky substance on the shelf. On July 30, 2024, at 2:30 p.m., an interview was conducted with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) regarding the refrigerator temperature. The DON stated all medication in the west medication room requiring refrigeration have been moved to the east wing medication room refrigerator until a proper placement can be made to replace the refrigerator. On July 30, 2024, at 2:45 p.m., an observation was made of the west wing medication cart with Staff H, Register Nurse (RN). One vial of Novolog was past its expiration based on it's opening date. Staff H agreed and removed the medication from the medication cart. On August 1, 2024, at 9:50 a.m., an observation was made of the east wing back medication cart with the ADON. One yellow band ring in a small bag not labeled and two labeled hearing aid containers were in one drawer with medication. The ADON stated no personal items should be in the medication 105549 Page 9 of 20 105549 08/01/2024 Aviata at the Harbor 1410 Dr Martin Luther King Jr St N Safety Harbor, FL 34695

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some carts. The ADON removed these items. An injection pen of Lantus was removed due to no documentation of an opening date and an insulin pen of Novolog was removed due to the manufacturing expiration date of (28 days) past the opening date. The ADON was in agreement with the findings of the medication cart. A record review of Resident #38's admission Record had an original admit date of 6/03/2022 with a readmission date of 7/22/2022. Resident #38 has a primary diagnosis of chronic obstructive pulmonary disease (COPD). Secondary diagnoses include but are not limited to unspecified dementia with unspecified severity without behavioral, psychotic, mood or anxiety disturbances, major depressive disorder, anxiety disorder unspecified, and chronic respiratory failure with hypercapnia. A record review of physician orders for Resident #38 has an order, dated 10/19/2023, for Combivent Respimat inhalation aerosol solution 20-100 MCG/ACT (Ipratropium-Albuterol) to give one puff inhale every six hours as needed for COPD. A physician order, dated 12/24/2023, for Incruse Ellipta inhalation aerosol powder breath activated 62.5 MCG/ACT (Umeclidinium Bromide) One puff inhale orally once daily for COPD. A physician order, dated 3/18/2024, for Ventolin HFA inhalation aerosol solution 108 (90 base) MCG/ACT (Albuterol Sulfate) two puffs inhale orally every four hours as needed for shortness of breath. Resident #38 did not have an order to self-administer medication. A record review of Resident #38's most recent care plan, dated 6/23/2024, has a focus area of cognitive deficit related to a diagnosis of dementia. Resident #38 has a focus area of COPD with a goal for resident to display optimal breathing patterns daily through review date and will be free of signs and symptoms of respiratory infections through review date. Interventions include but are not limited to: give aerosol/nebulizers or bronchodilators as ordered and monitor and document any side effects and effectiveness. Resident #38 did not have a care plan focus area to self-administer medications. On August 1, 2024, at 11:05 a.m., a telephone interview was conducted with the facility's pharmacist. The pharmacist stated he is at the facility at least monthly and will type up a report of his findings regarding medication storage as well as have a discussion of his findings with the DON. The pharmacist stated the ice in the west medication room was in his monthly report. A review of the Monthly Medication Unit Review, dated 7/05/2024, under Drug Storage Labeling, SecurityMedication Room shows the following observation from the monthly pharmacist rounds: [NAME] medication room needs a new light and consider defrosting refrigerator, build up in top near freezer area. On August 1, 2024, at 11:27 a.m., an interview was conducted with the DON regarding findings of medication carts, treatment cart, medication rooms and the inhaler found in Resident #38's bedside table. The DON stated the refrigerator in the medication room in the west wing has been replaced and education will be provided on proper labeling of medications The facility did not provide a policy on medication storage upon request. 105549 Page 10 of 20 105549 08/01/2024 Aviata at the Harbor 1410 Dr Martin Luther King Jr St N Safety Harbor, FL 34695

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to serve food at an appetizing temperature for five residents ( #90, #95, #29, #51 and #18) of five residents sampled for food services. Residents Affected - Some Findings included: 1. During an interview on 07/29/2024 at 10:15 a.m., Resident #90 stated he was frustrated with the food in the facility. He said that no fresh fruits or vegetables are ever given, and the food is over processed. He said he feels like he is losing weight. The resident stated he often orders a salad as a substitute from the Always Available Menu because he feels the food the facility is serving is not healthy. He said, This past weekend I wanted a chicken salad from the Always Available Menu and I was told there was no salad because they did not have any lettuce or tomatoes. The resident said the food is always the same and the facility never changes the menu. He stated he often has no breakfast meat. He said he has told the facility many times, but nothing has changed. An interview on 07/30/2024 at 2:20 p.m. revealed Resident #90 was upset and stated, The food today was terrible. The pork chop was so dry it was like leather. The food was cold. It had the white sauce on it and I couldn't stomach it, so I turned the tray away. He further said he declined an alternative choice because he had already lost his appetite. During an interview on 07/31/2024 at 9:17 a.m. Resident #90 stated the night before he requested a salad for dinner from the Always Available Menu. He said when he received his tray the diet slip was marked by the kitchen that they had no lettuce and no tomatoes for a salad (the resident did not save the diet slip from the tray). The resident stated a family member brought cereal to him for dinner. During an interview on 08/01/2024 Resident #90 said the Kitchen Manager has visited him the prior evening and asked the resident about his opinion of the food in the facility. The resident said, I let him have it. I told him exactly what has been happening with the food and how unhappy everybody is with it. I know almost everybody in this building, and nobody likes the food. The resident continued, Then this morning I get eggs for breakfast. I got cold scrambled eggs and two hard boiled eggs. That was it. No toast. Nothing else. The aide was nice enough to get a yogurt for me. Resident #90 showed a photograph, with date and time, of the breakfast he was served on this day. The resident stated the scrambled eggs are always cold. Review of Resident #90's admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses to include peripheral vascular disease, Type 2 Diabetes Mellitus, and morbid obesity. Review of Resident #90's Minimum Data Set (MDS), dated [DATE], revealed in Section C-Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. 2. During an interview on 07/29/2024 at 12:30 p.m., revealed Resident #95 expressed how he was very unhappy with the food in the facility. The resident stated he is diabetic and he is not receiving a proper diabetic diet. He said the food has a chemical taste, never smells good and is cold. The resident stated he feels like he has lost a lot of weight and has developed acid reflux since his admission to the facility, because of the food. 105549 Page 11 of 20 105549 08/01/2024 Aviata at the Harbor 1410 Dr Martin Luther King Jr St N Safety Harbor, FL 34695

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #95's admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses to include Type 2 Diabetes Mellitus, Peripheral Vascular Disease, Chronic Kidney Disease Stage 3, Gastro-Esophageal Reflux Disease. Review of Resident #95's Minimum Data Set (MDS), dated [DATE], revealed in Section C-Cognitive Patterns a BIMS score of 15, which indicated intact cognition. Review of Resident #95's physician orders revealed the resident's current diet order was Consistent Carbohydrates, Regular Texture, Regular/Thin Liquids, Consistent Carbohydrate 75 mg (milligrams). Review of Resident #95's weights revealed monthly weights of: May 179.0 lb, June 180.2 lb, July 173.6 lb. Resident has a weight loss from June to July was 6.6 lbs total. The resident weighed on 07/05/2024 and his weight was 172.0 lbs. Resident's weight is currently being done twice monthly. 3. During an interview on 07/29/2024 at 12:00 p.m., Resident #18 stated, the food here is really bad and what is on the menu isn't always what is available. The hot food is cold and the cold food is hot. Review of Resident #18's admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses to include Parkinson's Disease with Dyskinesia, Muscle Wasting and Atrophy, Osteoporosis, Vitamin D Deficiency, Gout, Chronic Kidney Disease. Review of Resident #18's Minimum Data Set (MDS), dated [DATE], revealed in Section C-Cognitive and Patterns a BIMS score of 15, which indicated intact cognition. 4. During an interview on 07/29/2024 at 10:46 a.m., Resident #29 expressed how unhappy she was with the food in the facility. The resident stated she is diabetic and never gets the proper diet. The resident said, What is on the menu is hardly ever what you get. The food is burned, the kitchen is always running out of food and food dishes are broken. The resident said the food is never the correct temperature and the hot food is always cold. Review of Resident #29's admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses to include Type 2 Diabetes Mellitus without Complications, Morbid (Severe) Obesity Due to Excess Calories, Essential Hypertension, Gout, Chronic Kidney Disease. Review of Resident #29's Minimum Data Set (MDS), dated [DATE], revealed in Section C-Cognitive Patterns a BIMS score of 15, which indicated intact cognition. 5. During an interview on 07/20/2024 at 9:29 a.m., Resident #51 stated the food in the facility is terrible and it doesn't taste good sometimes. She said, It doesn't look good and it's always the same. Review of Resident #51's admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses to include Type 2 Diabetes Mellitus, Muscle Wasting and Atrophy, Essential Primary Hypertension, Chronic Viral Hepatitis C. Review of Resident #95's Minimum Data Set (MDS), dated [DATE], revealed in Section C-Cognitive Patterns a BIMS score of 15, which indicated intact cognition. 105549 Page 12 of 20 105549 08/01/2024 Aviata at the Harbor 1410 Dr Martin Luther King Jr St N Safety Harbor, FL 34695

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 07/31/2024 at 9:30 a.m. a test tray was requested to be placed on the last tray cart leaving the kitchen for the lunch meal. The tray was to be delivered to the [NAME] Dining Room. Per the facility tray delivery schedule, the trays were to be delivered to the [NAME] Dining at 12:40 p.m. During an interview on 07/31/2024 at 10:44 a.m., Staff H (RN) stated whenever a resident tells him about a food complaint he tells the kitchen staff and they handle the issue. On 07/31/2024 at 1:00 p.m. the lunch trays were not yet delivered to the [NAME] Dining Room as indicated by the facility tray delivery schedule. At this time Staff J, Registered Nurse (RN) was interviewed and she verified the lunch trays were late. An observation in the [NAME] Dining Room on 07/31/2024 at 1:09 p.m. revealed the trays were delivered and after the last trays were delivered it was determined the test tray had been delivered to the conference room directly from the kitchen and not to the [NAME] Dining Room as requested. During an interview on 07/31/2024 at 1:12 p.m., Staff F, Food Service Director (FSD), stated the thermometer had been calibrated and was ready to take food temperatures. Staff F, FSD stated he expected food to be served at 140 degrees Fahrenheit (F) from the kitchen. The test tray lunch was encrusted pork loin, southern style pinto beans, braised cabbage, chocolate cake with peanut butter frosting and corn bread. The test tray food temperatures were completed, and results were as follows: -Pork Loin 123 degrees F -Pinto Beans 124 degrees F -Cabbage 117 degrees F -Cornbread 99 degrees F After the food temperatures were taken by FSD, Staff F stated he felt 123 degrees F was an appropriate temperature for the pork loin and he would eat it. An observation on 07/31/2024 at 1:12 p.m., showed no steam from the plate of hot food when the plate cover was removed. The state surveyor felt the pork loin and the pinto beans with finger and both food items were cool to the touch and not hot. On 07/31/2024 at 1:20 p.m. the Nursing Home Administrator (NHA) was interviewed and stated the test tray food was not palatable, attractive and at appetizing temperatures. He stated he would not eat it. 105549 Page 13 of 20 105549 08/01/2024 Aviata at the Harbor 1410 Dr Martin Luther King Jr St N Safety Harbor, FL 34695

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. Based on observations, interviews, and record review, the facility failed to ensure temperature logs were completed daily, the microwave in the nutritional room was kept clean and sanitary, and the kitchen reach-in refrigerator was not over packed with food items to keep cold foods at an appropriate safe temperature. Findings included: An observation, during the kitchen initial tour, on 07/29/24 at 9:06 a.m., revealed the walk-in refrigerator was not in service. During an interview on 07/29/24 at 9:07 a.m., Staff I, [NAME] stated the walk-in refrigerator quit working on 07/28/24 and this was reported to administration. Staff I, [NAME] stated all the food from the walk-in refrigerator was moved to the three-door reach-in refrigerator. During an interview on 07/29/24 at 9:08 a.m., Staff C, Interim Dietary Manager (IDM) stated Staff D, Dietary Manager (DM) just started today and was currently doing the morning rounds in the nourishment rooms. Further observations in the kitchen area on 07/29/24 at 9:20 a.m. revealed the following logs were not completed: - A Freezer Temperature Log showed no temperatures for the dates of 07/27/24 and 07/28/24. Photographic evidence obtained. - The reach-in Refrigerator Temperature Log showed no temperatures for the dates of 07/27/24 and 07/28/24. Photographic evidence obtained. - The Three Compartment Sink Log showed no temperatures for the dates of 07/27/24 for breakfast time and no dates for 07/28/24. Photographic evidence obtained. During an interview on 07/29/24 at 9:23 a.m., Staff D Dietary Manager (DM) stated he would have expected all temperature logs to be completed daily. An observation on 07/29/24 at 9:25 a.m. showed a three-door reach-in refrigerator with food packed inside with no additional space left on the shelves to put any other food items inside. An observation on 07/29/24 at 9:44 a.m. revealed a microwave located in the 200 Hallway Nourishment room. The microwave was opened and showed a sticky brown substance covering all over the inside of the microwave. Photographic evidence obtained. During an interview on 07/29/24 at 9:45 a.m., Staff F, Certified Nursing Assistant (CNA) confirmed the microwave was dirty and should have been cleaned. Staff F, CNA stated that it is the nursing staff who are responsible for cleaning the microwave daily with dietary staff who come daily, usually in the mornings, to ensure the nourishment rooms are clean and in good condition. Staff F, CNA stated the dietary staff must not have made their morning rounds yet or they should have caught the microwave being so dirty. 105549 Page 14 of 20 105549 08/01/2024 Aviata at the Harbor 1410 Dr Martin Luther King Jr St N Safety Harbor, FL 34695

F 0812 An observation, during follow-up in the kitchen, on 07/30/24 at 11:10 a.m., revealed Staff I, [NAME] beginning to do holding food temperature checks. The food temperatures were as follows: Level of Harm - Minimal harm or potential for actual harm Hot Foods: Residents Affected - Many - Hamburger: 172 degrees Fahrenheit (F) - Tater Tots- 165 degrees (F) - Puree hamburger- 169 degrees (F) - Mashed Potatoes- 142 degrees (F) - Mechanical soft meat- 181 degrees (F) Cold foods: - Tuna- 45 degrees (F) - Pasta salad- 53 degrees (F) - pureed cold vegetables- 60 degrees (F) During an interview on 07/30/ 24 at 11:15 a.m., Staff I [NAME] stated all the cold foods that were taken out of the three-door reach-in refrigerator had temperatures above 41 degrees (F). Staff I [NAME] stated they could always put the cold food back in to the three-door reach-in refrigerator to see if we can get them back to under 41 degrees (F). During an interview on 07/30/24 at 11:15 a.m., Staff D, DM stated because the walk-in refrigerator was out of order all the cold food had been placed in the three-door reach-in refrigerator, so the refrigerator was packed not allowing the air to properly circulate and keep the food inside properly cooled. The DM stated the cold food that had temperatures over 41 degrees (F) will need to be discarded and made brand new again prior to serving. Review of the facility policy Food Storage: Cold Foods, revised date 09/2017, showed the following: Policy Statement: All Time/Temperature Control for Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the [Food Drug Administration] FDA Food Code: .2. All perishable foods will be maintained at a temperature of 41 degrees Fahrenheit or below, except during necessary periods of preparation and service. 4. An accurate thermometer will be kept in each refrigerator and freezer. A written record of daily temperatures will be recorded. Review of the facility's policy Preventing Foodborne Illness-Food Handling, revised date July 2014, showed the following: 105549 Page 15 of 20 105549 08/01/2024 Aviata at the Harbor 1410 Dr Martin Luther King Jr St N Safety Harbor, FL 34695

F 0812 Policy Interpretation and Implementation. Level of Harm - Minimal harm or potential for actual harm 1. This facility recognizes that the critical factors implicated in foodborne illness are: Residents Affected - Many a. Poor personal hygiene of food service employees; Inadequate cooking and improper holding temperatures; .c. Contaminated equipment and d. Unsafe food sources . .5. Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day and documented according to state specific requirements. .9. All food service equipment and utensils will be sanitized according to current guidelines and manufactures' recommendations. 105549 Page 16 of 20 105549 08/01/2024 Aviata at the Harbor 1410 Dr Martin Luther King Jr St N Safety Harbor, FL 34695

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility 1) failed to ensure an effective infection control program related to Enhanced Barrier Precautions (EBPs) for three residents (#206, #202, and #203) out of four residents observed, and 2) failed to ensure appropriate personal protective equipment (PPE) was utilized during resident care for four residents (#206, #202, #203 and #83) out of four residents observed. Residents Affected - Some Findings included: On 7/29/2024 at 9:40 a.m., an observation and interview was conducted with Resident #203. Resident #203 was conversant and able to state she had a gastrostomy tube for nutrition and medication. Resident #203 stated since her admission she has not witnessed any staff member wear a gown during her care or medication administration via gastrostomy tube. No signage was observed on the outside of Resident #203's door to indicate EBPs were in place and no PPE was observed for staff use. On 7/29/2024 at 10:45 a.m., an observation and interview was made of Resident #202 during the initial tour. Resident # 202 had a Contact Isolation sign on the outside of her room with appropriate PPE supply on the door. When entering room, Resident #202 stated, This is the first time I've seen anyone wear a gown, mask and gloves, since I've been here - no one has done this. Resident #202 stated she does not know why she is on isolation, stating, I think maybe it's because I have an infection in my back. Staff Q, Licensed Practical Nurse (LPN) stated, Both residents have MRSA [Methicillin resistant staph aureus], bed A has it in her wound and bed B has it in her nares. An observation was made of Resident #202 with a peripherally inserted central catheter (PICC), dated 7/22/2024, and a wound vac connected to the resident. Resident #202 stated she had the PICC inserted at the hospital as well as the wound vac which is currently connected to a wound on her bottom. On 7/30/2024 at 10:30 a.m., a second observation was made of no EBPs signage for Resident #203. Resident stated she received her medication via gastrostomy tube this morning but she was hopeful a swallow study due today will let her eat. On 7/30/2024 at 10:55 a.m., an interview was conducted with the Infection Control Preventionist/Assistant Director of Nursing (IPC/ADON). The IPC/ADON stated when placing a resident requiring any form of isolation, she would use the 3008-communication form from the discharging hospital to their facility and obtain an order from the admitting facility physician to continue the isolation. On 7/31/2024 at 8:15 a.m., an observation was made of Staff J, Licensed Practical Nurse (LPN) in Resident #202's room finishing up an intravenous medication without a gown or mask in place as required by Contact Isolation guidelines. On 7/31/2024 at 8:30 a.m., an observation was made of the Assistant Director of Nursing (ADON) entering Resident #202's room wearing a gown, mask, and gloves. On 7/31/2024 at 9:50 a.m., an observation and interview was conducted with Staff J, LPN. Staff J, LPN administered medication via gastrostomy tube for Resident #83 without proper gown and gloves as required by Enhanced Barrier Precautions. Staff J, LPN stated she knew she was supposed to wear a gown and made a mistake. 105549 Page 17 of 20 105549 08/01/2024 Aviata at the Harbor 1410 Dr Martin Luther King Jr St N Safety Harbor, FL 34695

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 7/31/2024 at 10:45 a.m., an observation and interview was conducted with the Activities Director. This surveyor was in Resident #202's room in gown, gloves and mask during an interview. Resident #202 had a newly placed dressing over her PICC line with today's date. The resident stated, Some nurse was in here this morning and changed my dressing. During conversation the Activities Director entered the room without PPE to bring the resident the daily activities calendar. The Activities Director stated, I don't know what I'm supposed to wear, I see you are wearing all the PPE but I thought I did not have to if I was just coming in to talk to the residents. Now I don't know. On 7/31/2024 at 9:20 a.m., a third observation was made of no EBPs signage for Resident #203. On 7/31/2024 at 11:20 a.m., an observation was made of a Staff M, Certified Occupational Therapy assistant assisting Resident #206 out of bed into a wheelchair without a gown. On the outside of the room was a sign for Contact Isolation. Staff M stated she did not see the sign and was assisting the resident because she was getting out of bed On 7/31/2024 at 11:27 a.m., an interview was conducted with the DON, ADON and Regional Nurse Consultant regarding concerns of proper isolation and compliance with staff members. The ADON stated she would have to look at the residents' 3008 and guidelines to determine the proper isolation. The current signage for the Contact Isolation utilized by the facility states gown is to be worn for incontinence care. The Regional Nurse Consultant searched the Centers for Disease (CDC) website and printed the signage for Contact Isolation. A comparison was made of signs and agreed staff should be wearing a gown and gloves upon entering the resident's room. The DON stated Resident #203 was supposed to be on Enhanced Barrier Precaution since admission due to her gastrostomy tube. On 8/01/2024 at 9:50 a.m., the ADON stated one resident #203 was on Contact Isolation and Residents #202 and #206 were on Enhanced Barrier Isolation and not Contact Isolation. A record review of Resident #202's admission Record has an admit date of 7/23/2024 with a primary diagnosis of osteomyelitis of vertebra sacral and sacrococcygeal region. Secondary diagnoses include but are not limited to pressure ulcer of sacral region stage 4, flaccid neuropathic bladder, and paraplegia. A record review of the physician orders for Resident #202 shows an order, dated 7/23/2024, for catheter care every shift and as needed, change dressing on admission or 24 hours after insertion and weekly thereafter and as needed. Enhanced Barrier precautions dated 7/31/2024, and wound care to left buttocks cleanse with normal saline apply wound vac to run at 150 every Monday, Wednesday and Friday and as needed dated 7/29/2024. A record review of Resident #202's care plan, dated 7/24/2024, shows a focus area requiring enhanced barrier precautions related to use of indwelling medical device(catheter), chronic wound(s) and is at risk for a CDC MDRO (multisystem drug-resistant organism) infection. The goal is for the resident to have reduced risk of obtaining or transmitting CDC MDRO during the review. Interventions include but are not limited to staff to wear enhanced barrier precaution PPE when providing high contact direct care activities. A review of Resident #206's admission Record has an admit date of 7/20/2024 with a primary diagnosis of encounter for surgical aftercare following surgery on the skin and subcutaneous tissue. Secondary diagnoses include but are not limited to cutaneous abscess of buttocks, irritable bowel syndrome with diarrhea, and need for assistance with personal care. 105549 Page 18 of 20 105549 08/01/2024 Aviata at the Harbor 1410 Dr Martin Luther King Jr St N Safety Harbor, FL 34695

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident #206's physician orders have an order dated 7/31/2024 for Enhanced Barrier Precautions related to wound. A review of Resident #206's care plan, dated 7/23/2024, for enhanced barrier precautions related to a chronic wound(s) requiring a dressing/covering and is a risk for a CDC MDRO infection. The goal is for the resident to have a reduced risk of obtaining /transmitting a CDC MDRO during the review period. Interventions include but are not limited to staff to wear enhanced barrier precaution PPE when providing high contact direct care activities. A review of Resident #203's admission Record has an admit date of 7/23/2024 with a primary diagnosis of pathological fracture left femur subsequent encounter for fracture with routine healing. Secondary diagnoses include but are not limited to encounter for attention to gastrostomy, dysphagia pharyngeal phase and need for assistance with personal care. A review of Resident #203's physician orders have an order dated 7/23/2024 for enteral feed order every shift [NAME] Farms 1.5 (325 milliliters/ml) bolus three times a day for tube feeding and wound care left hip every three days and as needed. A review of Resident #203's care plan, dated 7/23/2024, for enhanced barrier precautions related to use of indwelling medical device (Peg tube) and is at risk for a CDC MDRO infection implemented on 8/01/2024. The goal is for the resident to have a reduced risk of obtaining/transmitting a CDC MDRO during the review period. Interventions include but are not limited to staff to wear enhanced barrier precautions PPE when providing high contact direct are activities. A review of the facility's policies and procedures titled, Enhanced Barrier Precautions, revised August 2022, shows the following: 1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms (MDROs) to residents. 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity as opposed to before entering the room. b. Personal protective equipment (PPE) is changed before caring for another resident. c. Face protection may be used if there is also a risk of splash or spray. 3. Examples of high contact resident care activities requiring the use of gown and gloves for EBP include: a. Dressing b. Bathing and showering c. Transferring 105549 Page 19 of 20 105549 08/01/2024 Aviata at the Harbor 1410 Dr Martin Luther King Jr St N Safety Harbor, FL 34695

F 0880 d. Providing hygiene Level of Harm - Minimal harm or potential for actual harm e. Changing linens f. Changing briefs or assisting with toileting Residents Affected - Some g. Device care or use (central line, urinary catheter, feeding tube, tracheostomy ventilator, etcetera; and h. Wound care (any skin opening requiring a dressing). . 9. No stop are trained prior to caring for residents on EBPs. 10. Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required. 11. Residents, families and visitors are notified of the implementation of EBPs throughout the facility. 105549 Page 20 of 20