Health inspection·July 15, 2021

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident observation and interview, medical record and policy reviews and interviews with nursing staff, the Director of Nursing (DON), and the Administrator, the facility failed to ensure that one resident (#60) out of twenty-seven sampled residents was properly assessed and monitored for self-administration of a nebulizer treatment. Residents Affected - Few Findings included: On 7/12/21 at 10:05 a.m. Resident #60 was observed sitting in a wheelchair at the bedside with a nebulizer treatment in progress with no nursing staff present in the room. Resident #60 stated he does the treatments on his own all the time and he receives several treatments a day. Resident #60 stated the nurse comes into the room and puts the medication into the cup and he does the treatment until all the medicine is done. Resident #60 stated the nurse does not stay in the room while the treatment is in progress. After five minutes had passed the resident took off the nebulizer mask, reached over and turned off the machine, and set the mask on the bedside table. Staff F, Licensed Practical Nurse (LPN) arrived in the room and asked the resident if he was done with the treatment. An interview was conducted with Staff F, LPN at this time. Staff F stated she went down the hall to bring her medication cart back to the room and left Resident #60 doing his nebulizer treatment. Staff F, LPN stated she was not aware if a self-administration of medications assessment had been completed for Resident #60. On 7/12/21 at 10:35 a.m. an interview was conducted with the DON. The DON stated the expectation for nurses when giving nebulizer treatments was to follow the doctors' orders. The DON indicated there was a policy in place for self-administration of medications and there was an assessment that is completed for residents who wish to do self-administration of medications. The DON was not aware if Resident #60 had an assessment completed. A copy of the policy for self-administration of medications and a copy of the assessment for Resident #60 was requested. A review of the medical record revealed Resident #60 was admitted to the facility on [DATE] with a diagnosis of metabolic encephalopathy, atrial fibrillation, major depressive disorder, hypertension, sleep apnea, transient ischemic attacks, and chronic obstructive pulmonary disease (COPD). A review of the July 2021 physician orders for Resident #60 revealed respiratory care orders for Albuterol Sulfate nebulizer solution 2.5 milligrams/3 milliliters 0.083% one vial inhale orally via nebulizer three times a day related to COPD with acute exacerbation; Breo Elllipta 100-25 micrograms/inhale aerosol powder breath activated one inhalation inhale orally one time a day for COPD and rinse mouth with water after use. An order dated 7/12/21 was written as may self-administer nebulizer treatment with license nurse. Page 1 of 16 105551 105551 07/15/2021 Aviata at Bradenton 105 15th St E Bradenton, FL 34208

F 0554 Level of Harm - Minimal harm or potential for actual harm A review of the admission Minimum Data Set Assessment (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 7, indicating severe cognitive impairment. A review of the comprehensive care plan for Resident #60 indicated the following focus areas associated with respiratory care: Residents Affected - Few Focus: Resident #60 has COPD, and it makes him short of breath and increases his chances of re-hospitalization (initiated 6/14/21). Goal: Will have a reduction of symptoms relating to COPD by allowing staff/doctor to provide interventions. Interventions: Administer medications as ordered. Focus: Resident #60 cognition is impaired as evidenced by decision making problems, short term memory problems, long term memory problems, diagnosis encephalopathy and noted with BIMS score of 7 (initiated 6/21/21). Goal: Maintain my current cognitive ability. Interventions: Report unanticipated changes in cognitive status to my physician. Focus: Resident #60 has a physician's order for self-administration of nebulizer treatments as ordered (set up by a licensed nurse) (initiated 7/12/21). Goal: The resident will take medications safely and as prescribed through the review date. Interventions: Monitor resident's self-administration and check on intervals through review date; Review medication self-administration with resident routinely and as needed to reassess abilities. On 7/13/21 at 3:40 p.m. the DON was asked again for a policy on self-administration of medications and the assessment for Resident #60. On 7/13/21 at 4:09 p.m. the DON brought the policy for review and stated he was not aware if an assessment had been done for Resident #60. The DON stated it may be in the chart on the floor. A review of the policy entitled, Resident Self-Administration of Medication, was implemented on 11/28/2017 and last reviewed/revised in 3/2021, an indicated the following: Policy: It is the policy of this facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. Policy explanation and compliance guidelines: 1. Resident preference will be documented on the appropriate form and placed in the medical record. 2. When determining if self-administration is clinically appropriate for a resident, the 105551 Page 2 of 16 105551 07/15/2021 Aviata at Bradenton 105 15th St E Bradenton, FL 34208

F 0554 interdisciplinary team should at a minimum consider the following: Level of Harm - Minimal harm or potential for actual harm --The medications appropriate and safe for self-administration --The resident's physical capacity to swallow without difficulty and to open medication bottles Residents Affected - Few --The resident's cognitive status, including their ability to correctly name their medications and know what conditions they are taken for --The resident's capability to follow directions and tell time to know when medications need to be taken --The resident's comprehension of instructions for the medications they are taking, including the dose, timing, and signs of side effects, and when to report to facility staff --The resident's ability to understand what refusal of medication is, and appropriate steps taken by staff to educate when this occurs --The resident's ability to ensure that medication is stored safely and securely 3. The results of the interdisciplinary team assessment are recorded on the Self-Administration Assessment Form, which is placed on the resident's medical record. A review of the medical record on 7/13/21 at 4:15 p.m. revealed a document entitled Self-Assessment for Medication Administration dated 7/12/21 on the back of the form by provider. The form was two sided and contained the following information: Side one Section A No response listed for Does resident wish to self-administer medications? Section B Assessment Criteria Had a check mark under Not Applicable for Question 1 Can correctly read aloud instructions for use on medication container? A check mark under Not Applicable for Question 10 Can correctly state situations warranting administration of PRN medications? A check mark under Not Applicable for Question 14 Can correctly self-administer inhalants. A signature was on the bottom of the page for Resident #60 with the room number. No other assessment questions were completed for Resident #60 on the Self-Administration Assessment. Side two Quarterly evaluation results--A check mark is indicated under Resident is deemed able to safely self-administer medications and yes is circled. No notes are provided. A signature is present and a date of 7/12/21. On 7/13/21 at 4:30 p.m. an interview was conducted with the Administrator and the DON. The Administrator stated the self-assessment document appeared to be incomplete. The DON confirmed the document did not appear complete and was dated 7/12/21 after the initial observation occurred for Resident 105551 Page 3 of 16 105551 07/15/2021 Aviata at Bradenton 105 15th St E Bradenton, FL 34208

F 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #60. The Administrator stated they try to make sure any areas brought to their attention are corrected and she would make sure the self-administration concern would be brought to Quality Assurance. On 7/14/21 at 11:55 a.m. Resident #60 was observed seated in his room in his wheelchair. The resident stated he had no recollection of anyone asking him to sign a document about self-administration of medications. Review of policy entitled, Nebulizer Therapy, with an implementation date of 11/28/17 indicated the following: Policy: It is the policy of this facility for nebulizer treatments, once ordered, to be administered by nursing staff as directed using proper technique and standard precautions. Care of the Resident: 6 Obtain resident's vital signs and perform respiratory assessment to establish a baseline. 8 Place ordered medications into nebulizer cup, and mouthpiece per manufacturer's specifications and ensure connections are secured tightly. 9 Assist resident into a comfortable position. If possible, place resident in an upright position to encourage full lung expansion and promote aerosol dispersion. 13 Keep nebulizer vertical during treatment 14 Observe resident during the procedure for any change in condition. 105551 Page 4 of 16 105551 07/15/2021 Aviata at Bradenton 105 15th St E Bradenton, FL 34208

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview and record review, the facility failed to maintain resident dignity during dining for four of four days observed (7/12/2021, 7/13/2021, 7/14/2021, and 7/15/2021). It was determined that seven staff members (A, B, C, D, E, H, and L) were not consistently knocking or announcing themselves prior to entering 12 occupied resident rooms (room [ROOM NUMBER], 104, 105, 108, 113, 119, 121, 130, 131, 132, 203, and 207), and two staff members (A and M) were observed standing up as they provided eating assistance for four residents (#7, #58, #63, and #38), who were seated, of a total sample of twenty-seven residents. Findings included: On 7/12/2021 the following observations were made: a. At 12:20 p.m. a certified nursing assistant (CNA), Staff A was observed to walk up to resident room [ROOM NUMBER] and proceed to walk in the room to drop off a lunch tray without first knocking and or announcing. There was a resident in the room at the time she walked in. b. At 12:22 p.m. a Licensed Practical Nurse (LPN), Staff B was also observed to walk up to room [ROOM NUMBER] and walk in to drop off a lunch meal tray without first knocking or announcing. There was a resident in the room at the time. c. At 12:24 p.m. a Registered Nurse (RN), Staff C was observed to walk up to resident room [ROOM NUMBER] and walk in to drop off a lunch meal tray without first knocking and or announcing. There was a resident in the room at the time. d. At 12:25 p.m. Staff B, LPN was observed to walk into resident room [ROOM NUMBER] to take in a lunch meal tray and did not knock or announce prior to entering the room. There was as resident in the room at the time. e. At 12:26 p.m. Staff C, RN was observed to walk up to resident room [ROOM NUMBER] and walk in without first knocking and or announcing. There was a resident in the room at the time of the observation. f. At 12:27 p.m. Staff A, CNA was also observed to take a meal tray to room [ROOM NUMBER] and walk in without first knocking and or announcing. There was a resident in the room at the time of the observation. On 7/13/2021 the following observations were made: g. At 7:17 a.m. Staff D, CNA was observed to walk up to resident room [ROOM NUMBER] with a breakfast tray and proceeded to walk in the room without first knocking and announcing. There were residents in the room at the time of the observation. h. At 7:18 a.m. Staff E, CNA was observed to walk up to resident room [ROOM NUMBER] and proceeded to walk in the room without first knocking and or announcing. There were residents in the room during the time of the observation. 105551 Page 5 of 16 105551 07/15/2021 Aviata at Bradenton 105 15th St E Bradenton, FL 34208

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some i. At 7:23 a.m. Staff E, CNA was observed to walk into resident room [ROOM NUMBER] and did not first knock or announce prior to walking in. There were residents in the room during the time of the observation. j. At 7:45 a.m. a Unit Supervisor, Staff G was observed carrying a breakfast tray down the hall to room [ROOM NUMBER]. He proceeded to walk in the room without first knocking and or announcing. There was a resident in the room during the time of the observation. On 7/14/2021 the following observations were made: k. At 12:20 p.m. Staff H, LPN was observed to take a meal tray from the tray cart and walk to resident room [ROOM NUMBER] and proceeded to walk in with the tray without first knocking and our announcing. There were two residents in the room at the time of the observation. l. At 12:24 p.m. Staff A, CNA was observed to carry a lunch meal tray to resident room [ROOM NUMBER]. She proceeded to walk in the room without first knocking or announcing. There was one resident in the room during the time of the observation. m. At 12:35 p.m. Staff L, CNA was observed to walk to resident room [ROOM NUMBER] and proceeded to walk in with a meal tray without first knocking and or announcing. There were residents in the room during the time of the observation. n. At 12:38 p.m. Staff H, LPN was observed to walk to resident room [ROOM NUMBER] and walked into the room without first knocking and or announcing. She spoke to the resident after already halfway into the room. There were residents in the room during the time of the observation. On 7/15/2021 the following observations were made: o. At 7:30 a.m. Staff A, CNA was observed to walk to resident room [ROOM NUMBER] and proceeded to walk in the room without first knocking and or announcing. There were residents in the room during the time of the observation. p. At 7:38 a.m. Staff L, CNA was observed to walk down the hallway from the nurse station and then walked into resident room [ROOM NUMBER] without first knocking or announcing. There were two resident in the room during the time of the observation. On 7/14/2021 at 7:29 a.m. Resident #38 was observed in her room and dressed for the day, seated and reclined slightly while in her Specialized chair. Staff I, CNA had brought in a breakfast tray for Resident #38. Staff I set up the tray on the over the bed table and positioned it next to the resident. Further, the CNA was observed to stand up and assist the resident with eating. She took forkfuls of food items and brought them to the resident's mouth. Staff I stood up and assisted Resident #38 from 7:29 a.m. to 7:37 a.m. The South Unit Manager at 7:38 a.m. went into the room and then told Staff I to sit down while providing eating assistance. She then got a chair and sat down next to the resident and continued to assist with feeding Resident #38 forkfuls of food items. Following this observation, Staff I confirmed that she should have been seated next to the resident at head level and not standing up when assisting the resident with eating. On 7/12/2021 at 1:00 p.m. random interviews with Residents #16, #68, #42, who were deemed interviewable per observations and review of their medical record; as well as four random alert and oriented 105551 Page 6 of 16 105551 07/15/2021 Aviata at Bradenton 105 15th St E Bradenton, FL 34208

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some residents, who all wished to remain anonymous, revealed that staff, during all shifts, walk in the room and don't say anything until they are in the room. The residents interviewed confirmed that staff are not consistently knocking and or announcing prior to entering their room. Some revealed that they have not complained about it because they did not feel things would get better and did not want to get staff in trouble. The residents interviewed did say they would like for staff to announce or knock prior to coming in their rooms. On 7/15/2021 at 1:40 p.m. an interview with the Staff G, South Unit Manager confirmed that staff should be seated at resident level when providing Eating assistance. He further confirmed that staff, after setting up the meal tray, should not be standing up to assist the resident. The South Unit Manager further confirmed that staff should always knock and or announce prior to entering occupied resident rooms. On 7/15/2021 at 2:00 p.m. during an interview with both the Director of Nursing and the Nursing Home Administrator both confirmed that staff should always knock and or announce prior to entering occupied rooms, even when they have a meal tray in hand. On 7/15/2021 at 2:15 p.m. the Director of Nursing provide the Resident Rights, Policy and Procedure, dated 11/28/2017, for review. The Policy Explanation and Compliance Guidelines #11 showed; The facility will ensure that all staff members are educated on the rights of residents and the responsibility of the facility to properly care for its residents. Further review of the policy #5 Respect and Dignity revealed; The resident has the right to be treated with respect and dignity, C. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preference, except when to do so would endanger the health or safety of the resident or other residents. The Director of Nursing, at this time, explained that they did not have a specific Policy and Procedure related to Eating assistance dignity and or not Knocking and or Announcing prior to entering resident rooms. He did say that the Resident Rights Policy would encompass those areas. During the lunch meal observation on 07/12/21 at 12:09 p.m. Staff A, CNA was observed through the open door from the hallway assisting Resident #7. Staff A was standing next to Resident #7 who was sitting up in the bed, Staff A was standing facing Resident #7 who was on her right, and was serving from the bedside table on her left, the window bed resident was being assisted by Staff C, RN who was seated at the resident ' s right bedside. During the lunch meal observation the following day on 07/13/21 at 12:21 p.m. Staff M, LPN was observed through an open door from the hallway assisting Resident #63 who was seated in a recliner chair at the door bedside. Staff M, LPN was standing next to the chair on the resident's right with the meal on the bedside table to her right and was assisting with the dining experience. A subsequent observation at 12:41 p.m. of Staff M, LPN from an open door from the hallway, revealed she was assisting Resident #58 with the lunch meal, who was seated in a high back wheelchair in her room by the window, Resident #58 was sitting facing the hallway and Staff M, LPN was on her left with the lunch meal on the bedside table in front of her, Staff M, LPN was at times assisting with the dining experience and at other times was providing cueing for the resident who was feeding herself all the while standing over Resident #58. 105551 Page 7 of 16 105551 07/15/2021 Aviata at Bradenton 105 15th St E Bradenton, FL 34208

F 0557 Level of Harm - Minimal harm or potential for actual harm An interview with Staff Q, CNA on 07/15/21 at 12:01 p.m. revealed that the training she received at this facility related to a dignified dining experience included being seated at eye level with the resident, she added that if there wasn't a chair at the bedside when she was delivering the tray and she would not leave the tray in the room but would return with the tray once she had secured a chair for herself while she assisted. Residents Affected - Some A subsequent interview completed at 12:25 with Staff B, LPN confirmed that in order to provide a dignified dining experience for the resident, the facility trains the staff to ensure that there is seating available next to the resident in order to be at eye level. Staff B, LPN provided the most recent training record related to assisting residents with a meal. A review of the attendance and content of this in-service completed on 05/17/21 revealed the following, Topic: Assisting Patient With Meals: Patient [s] who require assist [ance] with meals must be set up and staff is to frequently check and assist patient with meal trays. When assisting a patient with their meals staff must sit. Allow patient [s] who are able to feed self [to] do so, this will encourage independence, provide queuing and assistance when needed. The attendance sheets included signatures from Staff A, CNA and Staff M, LPN. 105551 Page 8 of 16 105551 07/15/2021 Aviata at Bradenton 105 15th St E Bradenton, FL 34208

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to provide one resident (#28) of five sampled residents or their representative, with a completed written copy of the Nursing Home Transfer and Discharge Form when transferred emergently to an acute care facility. Findings included: A review of the admission Record revealed that Resident #28 was originally admitted to the facility on [DATE]. Her principal diagnosis was for unspecified sequelae of cerebral infarction, other pertinent diagnoses included but were not limited to a cognitive communication deficit, and hemiplegia/hemiparesis following the cerebral infarction affecting the left non-dominant side. Her Brief Interview for Mental Status (BIMS) assessment from the Minimum Data Set (MDS) dated [DATE] revealed a score of 00 indicating that Resident #28 either did not respond to the questions or answered all of the questions incorrectly. The Resident's family member was noted as the responsible party on Resident #28's admission Record. A review of the nursing progress note dated 03/20/21 at 02:15 a.m. revealed that Resident #28 was observed to be flushed, non-communicative and glassy eyed. The objective symptoms included a capillary blood sugar of 424 and blood pressure readings of 154/116. The medical doctor was called and an order to send Resident #28 to the hospital for evaluation was obtained. The progress note documented the notification and agreement of Resident #28's emergency contact for the transfer. A review of the Nursing Home Transfer and Discharge Form dated 03/20/21 revealed a partially filled-out form. The section of the form identifying the Nursing Home Administrator/Designee Name was blank with an illegible signature, the Physician/Designee Name was blank, the Notice Received by section included the words contacted name of family member, and was dated 03/20/21 and there was no signature. The Notice give to section for Resident, Legal Guardian or Representative had a date of 3/20/21 documented. An interview with Staff K, Social Services was conducted on 07/13/21 at 3:22 p.m. Staff K confirmed that he sends a notification at the time of the transfer to the State Long-Term Care Ombudsman's office via fax. Staff K stated he does not send any other notifications. He stated that nursing calls the resident's representative or emergency contact when they send the resident out, he stated that he was not aware of any other notifications. A review of the facility's policy dated 11/28/17 last revised 01/04/21, entitled, Transfer and Discharges & Against Medical Advice (AMA), revealed the following, Policy: It is the policy of this facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility except in the limited situations when the health and safety of the individual or other residents are endangered .7. Emergency Transfer/Discharges - initiated by the facility for medical reasons .i. Provide a notice of the resident's bed hold policy to the resident and representative at the time of transfer, [as soon] as possible, but no later than 24 hours of the transfer. J. Provide transfer notice as soon as practicable to [the] resident and representative. An interview with the Nursing Home Administrator (NHA) conducted on 07/15/21 at 11:22 a.m. confirmed that a written notice, and a notice of the bed hold including charges was not given to Resident 105551 Page 9 of 16 105551 07/15/2021 Aviata at Bradenton 105 15th St E Bradenton, FL 34208

F 0623 #28 responsible party. The NHA stated that she had just become aware that there was a lapse in the facility's process related to the written notifications required with a resident transfer. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 105551 Page 10 of 16 105551 07/15/2021 Aviata at Bradenton 105 15th St E Bradenton, FL 34208

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to provide two residents (28 and 66) of five sampled, or their representative, with a written copy of the bed hold notice when they were transferred emergently to an acute care facility. Findings included: 1. A review of the admission Record revealed that Resident #28 was originally admitted to the facility on [DATE]. Her principal diagnosis was for unspecified sequelae of cerebral infarction, other pertinent diagnoses included but were not limited to a cognitive communication deficit, and hemiplegia/hemiparesis following the cerebral infarction affecting the left non-dominant side. Her Brief Interview for Mental Status (BIMS) assessment from the Minimum Data Set (MDS) dated [DATE] revealed a score of 00 indicating that Resident #28 either did not respond to the questions or answered all of the questions incorrectly. The Resident's family member was noted as the responsible party on Resident #28's admission Record. A review of the nursing progress note dated 03/20/21 at 02:15 a.m. revealed that Resident #28 was observed to be flushed, non-communicative and glassy eyed. The objective symptoms included a capillary blood sugar of 424 and blood pressure readings of 154/116. The medical doctor was called and an order to send Resident #28 to the hospital for evaluation was obtained. The progress note documented the notification and agreement of Resident #28's emergency contact for the transfer. A review of the form titled, Temporary Leave - Bed Hold Policies, indicated that Resident 28's family member was verbally notified on 3/20/21 and provided consent. There was no documentation in the medical record to indicate the bed hold notice was provided in writing to the family member. 2. A review of the admission record for Resident # 66 revealed the resident was admitted to the facility on [DATE] with the primary diagnosis of encounter for surgical aftercare following surgery on the digestive system. Other pertinent diagnoses included but were not limited to bipolar disorder, panic disorder, Type II Diabetes, Chronic Obstructive Pulmonary Disease (COPD), and mild cognitive impairment. Resident # 66's BIMS score from the MDS dated [DATE] was documented as a 10, indicating a mild cognitive impairment. Review of the nurse progress notes for Resident #66 revealed that she began to complain of abdominal pain during the late afternoon on 06/11/21, despite orders for treatment and medication administration Resident #66's condition did not improve and Resident #66 called 911 for transfer to the hospital at 8:15 p.m. that evening. A progress note on 06/11/21 at 10:22 p.m. documented by nursing revealed that Resident #66's physician and responsible party were notified of this event. An interview with the Director of Nursing (DON) on 07/13/21 at 3:05 p.m. revealed that Resident #66 called the emergency services herself, the DON stated that nursing called the physician to let him know. The physician decided to send her to the hospital for evaluation and nursing completed an emergency transfer, the DON provided the patient transfer form completed on 06/11/21 at 19:35 (7:35 p.m.), it documented a phone notification to Resident #66's family. The reason for the transfer was documented as abdominal pain. 105551 Page 11 of 16 105551 07/15/2021 Aviata at Bradenton 105 15th St E Bradenton, FL 34208

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview with Staff J, Licensed Practical Nurse (LPN) was conducted on 07/14/21 at 4:47 p.m. Staff J, LPN stated that the nurse sends a copy of the bed hold policy with the resident when there is a transfer to the hospital. Staff J, stated that a signature is obtained by the resident or the responsible party at admission and that the admission nurse instructs the resident or family member that the form will be used in the event that a transfer is needed during the stay. The Resident or responsible party's signature is obtained at admission for the acknowledgement of the bed hold policy. The form at that time does not include any of the specifics such as the amount the Resident would be charged for holding the bed, or the availability of a bed for the Resident to return to. An interview with Staff K, Social Services was conducted on 07/13/21 at 3:22 p.m. Staff K confirmed that he sends a notification at the time of the transfer to the State Long-Term Care Ombudsman's office via fax. Staff K stated he does not send any other notifications. He stated that nursing calls the resident's representative or emergency contact when they send the resident out, he stated that he was not aware of any other notifications. A review of the facility's policy dated 11/28/17 last revised 03/21, entitled, Bed Hold Notice Upon Transfer, revealed the following, Policy: At the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or the resident representative written notice which specifies the duration of the bed-hold policy and addresses information explaining the return of the resident to the next available bed .2. In the event of an emergency transfer of a resident, the facility will provide within 24 hours written notice of the facility's bed-hold policies, as stipulated in the State's plan . 5. The facility will keep a signed and dated copy of the bed-hold notice information given to the resident and/or resident representative in the resident's file. An interview with the Nursing Home Administrator (NHA) conducted on 07/15/21 at 11:22 a.m. confirmed that a written notice, and a notice of the bed hold including charges was not given to Resident # 28's or Resident # 66's responsible parties. The NHA stated that she had just become aware that there was a lapse in the facility's process related to the written notifications required with a resident transfer. 105551 Page 12 of 16 105551 07/15/2021 Aviata at Bradenton 105 15th St E Bradenton, FL 34208

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview and medical record review, the facility failed to ensure one resident (#45) of twenty-seven sampled residents was provided with supervision and assistance with eating during three of four days observed (7/12/2021, 7/13/2021, and 7/14/2021). Residents Affected - Few Findings included: On 7/12/2021 at 1:24 p.m. Resident #45 was observed in her room with her lunch meal tray placed in front of her on the over the bed table. There were no staff in the room during the time of the observation. Resident #45 was not interviewable as she was not able to answer questions related to her care and services. She was observed with a pureed textured diet and with several cups of juices. Resident #45 was observed with her right hand, pushing, and scraping food off of the plate and it was falling on her lower neck and shirt. Resident #45 was also observed trying to scoop her juice from her cup with her fork. Resident #45 was served her meal at 12:50 p.m. and had not been visited from staff until after 1:26 p.m. The resident did not receive any supervision, assistance, nor was checked on for over thirty-six minutes. Staff came into the room at 1:26 p.m. to remove the tray. On 7/13/2021 at 7:36 a.m. Staff G, South Unit Manager was observed to walk a breakfast tray into Resident #45's room and placed it on top of the over the bed table. Resident #45 was observed with the head of her bed at approximately forty-five degrees. However, her head was level with the top surface of the over the bed table. The Staff G set up the breakfast tray and left the room at 7:38 a.m. Then at 7:51 a.m. Staff F, Licensed Practical Nurse (LPN) walked to the room doorway and asked how the roommate was. She did not check on Resident #45. Then at 7:52 a.m. Resident #45 was observed again with her head at the same level as the top surface of the over the bed table. She was trying to scoop food from her plate, and scooped some food onto the top surface of the table and brought food to her mouth. Food was observed to drop off onto her gown. Resident #45 continued to push food all around her plate with her fork. She was not observed grabbing her juice or water glass since being served at 7:36 a.m. Staff F, LPN was observed at 7:58 a.m. to walk to the room again and check on the roommate. She opened the milk carton and then went into the bathroom. Staff G, South Unit Manager at 8:00 a.m. walked into the room to check on Resident #45, which was twenty minutes after he left from setting up the meal. There was no assistance, checking on the resident or cueing for over twenty minutes. On 7/14/2021 at 7:20 a.m. Resident #45 was observed in her room and lying in bed flat with her head on her pillow with her eyes closed. She was observed under the sheets and with the call light placed within her reach. She had the over the bed table at the side of her bed and with the top surface positioned away from her head approximately one foot and with her head below the table surface approximately one foot. The table was observed with one carton (unopened) of milk, a glass of red juice and a glass of water. They were all out from her reach. On 7/14/2021 at 7:30 a.m. Staff A, Certified Nursing Assistant (CNA) was observed to bring a breakfast tray into the Resident 45's room and set it up and left the room at 7:31 a.m. Then at 7:48 a.m. the resident was observed with her breakfast tray to include one plate with pureed food items, two bowls with pureed food items, four cups of thickened liquids. Resident #45 was able to scoop from the plate, but she did not do so from the bowls. Drinks were untouched as well. 105551 Page 13 of 16 105551 07/15/2021 Aviata at Bradenton 105 15th St E Bradenton, FL 34208

F 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Staff G, South Unit Manager was observed to go in the room at 7:50 a.m. and check on the resident, which was 19 minutes after being served. On 7/14/21 at 12:33 p.m. an aide was observed to bring Resident #45 a lunch meal tray and placed it on the over the bed table. She was observed to set up the meal tray for the resident and then left the room at 12:36 p.m. Staff A, CNA was observed to walk in the room at 12:40 p.m. and went over to the resident. Resident #45 was observed tapping the plate with a fork, in an area where there was no food. Staff A then turned the plate in a direction where the resident could easily scoop the food items. Staff A confirmed Resident #45 did not have a scoop plate, divider plate, or builtup eating utensils. She confirmed that she does have to turn the plate for her at times in order for her to reach the food items easily. Staff A revealed she believes the resident had speech therapy in the past but not currently and does require limited eating assistance with one person assist. Review of Resident #45's medical record revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the admission diagnosis sheet revealed diagnoses to include: dementia, speech and language deficit, major depression, anxiety, adult failure to thrive, and dysphagia. Review of the following Minimum Data Set (MDS) assessments revealed: - Annual MDS dated [DATE] - (Cognition/Brief Interview Mental Status BIMS score - no score but indicated Long Term/Short Term memory problems and with severely impaired decision making skills); Activity of Daily Living ADL - Eating supervision with set up only. - Significant Change MDS dated [DATE] - (Cognition/BIMS score - no score Long Term/Short Term memory problems and with severely impaired decision making skills); ADL - Eating Limited Assistance with one person physical assist. Through review of the last two MDS assessments, it was determined that Resident #45 had declined with her Eating ADLs. A review of the Speech Therapy Screen dated 7/8/2021 documented: Self feeding - Limited verbal limitations. Speech Therapy not recommended at this time. Review of the Speech Therapy assessment dated with start of care 7/12/2201 through to (no date) revealed: Treatment diagnosis: Dysphagia, oropharyngeal, Reason for referral - Resident was referred to therapy as patient who no longer receiving Hospice services. Has history of Dysphagia. Review of the nurse progress notes revealed: -7/3/2021 05:00 (a.m.) - Alert needs anticipated and met by staff requires total assist of one with all care fed by staff with 50 - 75% of meals consumed remains on honey thick liquids with good intake consumes 100% of med shake supplement incontinent of B&B. -7/8/2021 09:52 (a.m.) - DIETARY - Significant change. During this review period resident is on a Puree with Honey thick liquids. She has swallowing problems. She will eat 25 - 100% of most of her meals. No longer followed by Hospice. -7/10/2021 03:15 (a.m.) - Alert with confusion needs anticipated met by staff incontinent of B&B kept clean dry by staff skin warm dry intact. Pureed diet with honey thick liquids consumes 25 - 100% 105551 Page 14 of 16 105551 07/15/2021 Aviata at Bradenton 105 15th St E Bradenton, FL 34208

F 0676 of meals fed by staff honey thick shake for supplement three times a day. Level of Harm - Minimal harm or potential for actual harm Review of the current care plans with next review date of 7/16/2021 revealed the following; Residents Affected - Few - Has chewing and swallowing difficulties and has dementia. She is at a nutritional risk and with interventions to include: Assist with meals as need - able to feed self at times, needs assist at times. - ADL self care performance deficit r/t (related to) dementia, impaired balance, generalized weakness, and is comfort and care. She requires extensive to total assist with ADL self care, with interventions to include, but not limited to: Assist with ADL self care as needed to maintain dignity; EATING, Provide finger foods when the resident has difficulty using utensils. On 7/14/2021 at 1:30 p.m. an interview with two MDS coordinators, Staff B, Licensed Practical Nurse (LPN) and Staff C, Registered Nurse (RN) revealed that Resident #45 has had a recent significant change with her Minimum Data Set (MDS), which included resident coming off of Hospice services. Both MDS coordinators reviewed the last Annual MDS assessment dated [DATE] and confirmed the Activities of Daily Living (ADL) section revealed Resident #45 only required Supervision and with Set up only for Eating ADLs. Staff C, RN revealed that Supervision meant that staff would be in the room and set up the meal tray and then to continually check on the resident to see how they were effectively eating. Staff C revealed that staff would not necessarily have to stay in the room the entire time but would need to check on the resident frequently. Staff B and Staff C confirmed the most current MDS assessment (Significant Change) dated 7/7/2021) related to the ADL section that revealed Resident #45 had declined with eating and now required Limited Assistance, with One Person Physical Assist. Further interview with the MDS Coordinators revealed that expectation for Limited Assist, and with One Person Assist. The expectation was that staff are in the room with the resident and assist at times with feeding assistance, and cueing. The MDS Coordinators further confirmed that it would be expected that staff check on the resident frequently. When asked if revisiting Resident #45 every fifteen minutes or twenty-six minutes would be a good expectation, both indicated that a resident who was Limited Assist, or with One Person Assist, would mean staff would have to check on them more frequently than that and the above mentioned timeframes were not acceptable. The MDS Coordinators both confirmed that Resident #45 has a very low cognition and would not be able to speak and be interviewed related to her care and services, to include ADL assistance. On 7/15/2021 at 7:47 a.m. Resident 45's room was observed. She was being visited by multiple staff members to include an Occupational Therapist, Staff P. Staff P indicated he was referred yesterday on 7/14/2021 to assess and observe the resident. He said, per his observation this morning during the breakfast meal, the resident was able to mostly do her eating tasks on her own but knows that she does have times when she needs assistance with eating. He revealed that it could be beneficial for her to use built up eating utensils to help her scoop food better and will now pick the resident up for Occupational Therapy case load. On 7/15/2021 at 10:00 a.m. the Staff G, South Unit Manager was interviewed related to Resident #45 and her ADL assistance requirements. He did indicate that Resident #45 does need supervision and some assistance at times with Eating assistance and she has been known to push food off her plate at times. He revealed that staff should be checking on her often and would have needed supervision more frequently than the observed thirty-six minutes on 7/12/2021, twenty minutes on 7/13/2021, and nineteen minutes on 7/14/2021. He confirmed that staff should have been visiting Resident #45 before those 105551 Page 15 of 16 105551 07/15/2021 Aviata at Bradenton 105 15th St E Bradenton, FL 34208

F 0676 times. Level of Harm - Minimal harm or potential for actual harm On 7/15/2021 at 2:00 p.m. the Director of Nursing provided the Activities of Daily Living (ADL), policy and procedure, with a last revised date of 4/14/2021. The Policy showed: The facility will ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable to include Eating abilities. Residents Affected - Few Further review, under Policy Explanation and Compliance Guidelines: #3., revealed: A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. 105551 Page 16 of 16