Health inspection·July 11, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to identify and report an allegation of physical abuse by a staff member for one (#314) of three residents reviewed for abuse. Findings Included: A review of the admission Record showed Resident #314 was most recently admitted to the facility on [DATE] with diagnoses to include cerebrovascular Accident (CVA), aphasia, hemiplegia, depression, and legal blindness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #314 had a Brief Interview Status (BIMS) score of 14 out of 15, indicating intact cognition. Resident #314 needed maximum assistance with one-person physical assistance with bed mobility, dressing, toilet use, and personal hygiene, and extensive assistance with two plus persons physical assistance with transfers. During an interview on 7/8/2024 at 9:17 AM, Resident #314 reported a concern regarding not being able to get up into a wheelchair. Review of the grievance log, from April 2024 to current, revealed a grievance for Resident #314 dated 4/13/2024. Review of the grievance for Resident #314, written by the Nursing Home Administrator (NHA), revealed Resident #314 reported to Staff I, Licensed Practical Nurse (LPN) that the resident was uncomfortable when the Certified Nursing Assistant (CNA) was providing care. Attached to the grievance form was an In-Service Attendance record, with two pages of nursing staff signatures of attendance for the topic Customer Service, Summary our number one goal is to provide friendly and timely customer service with respect. When dealing with a resident, please ensure you are not rude or making a resident feel there is an issue. While providing Activities of Daily Living (ADL) care, CNA's must talk through every step with courtesy. If the resident/family asks something of you that you either don't have the answer to or can't perform, be sure to notify the immediate supervisor. Also attached to the grievance was the document titled Skills Competency Assessment: Positioning a Resident, dated 4/19/24 by Staff K, Certified Nursing Assistant (CNA) and the evaluator's signature. During an interview on 7/11/2024 at 9:10 AM Staff I, LPN stated the CNA let me know Resident #314 complained about something. Staff I, LPN stated she could not recall much other than informing the Nursing Home Administrator (NHA). Staff I LPN said the complaint could have gone in any direction (regarding abuse or not). Page 1 of 16 105644 105644 07/11/2024 Aviata at Fletcher 518 W Fletcher Ave Tampa, FL 33612

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 7/11/2024 at 9:19 AM Staff K, CNA recalled the incident on 4/13/2024. Staff K, CNA stated Resident #314 told Staff I, LPN, I had hit him when providing care. Staff K, CNA continued to state the NHA had not spoken to her regarding the incident. Staff K, CNA said she only spoke to Staff E, LPN/West Unit Manager. Staff E, LPN/West Unit Manager changed my resident assignment so I was no longer caring for Resident #314. Staff K, CNA said she went back to Resident #314 and told stated, you can't say things that aren't true, you will get me in trouble. On 7/11/2024 at 9:31 AM, Staff E, LPN/West Unit Manager could not recall the incident that occurred in April 2024 involving Resident #314. Staff K, CNA was asked to join the interview with Staff E, LPN/West Unit Manager. Staff K, CNA recalled the event of Resident #314 alleging that she hit him. Staff E, LPN/West Unit Manager recalled Resident #314 hitting Staff K, CNA not Staff K, CNA hitting the resident. Staff E, LPN/West Unit Manager stated If the resident did say he was hit, we would have suspended Staff K, CNA until an investigation was completed as this would be reportable. On 7/11/2024 at 10:05 AM, the NHA stated not recalling the incident. Review of the Reportable Log dated April 2024 revealed no abuse report being completed for Resident #314. Review of the facility's policy and procedures with the subject: Abuse, Neglect, Exploitation and Misappropriation with a revision date of 11/16/2022 revealed: Policy: it is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and/or misappropriation of property. Procedure: 7. Reporting/Response: any employee or contracted service provider who witnesses or has knowledge of an act of abuse or an allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, to a resident is obliged to report such information immediately, but no later than two hours after the allegation is made, if the events that caused the allegation involve abuse or result in bodily injury, or not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury to the administrator and to other officials in accordance with state law. In the absence of the executive director, the director of nursing is the designated abuse coordinator. Once an allegation of abuse is reported, the executive director, as the abuse coordinator, is responsible for ensuring the reporting is completed timely and appropriately to the appropriate officials in accordance with federal and state regulations, including notification of law enforcement if a reasonable suspicion of crime has occurred. 105644 Page 2 of 16 105644 07/11/2024 Aviata at Fletcher 518 W Fletcher Ave Tampa, FL 33612

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interview the facility failed to complete an accurate Minimum Data Set (MDS) assessment that accurately reflected the dental status for one (#21) of 48 sampled residents. Residents Affected - Few Findings Included: Interview with Resident #21 on 07/08/24 at 3:38 PM revealed he has had some toothache pain recently and that the facility puts cream on it. He reported that the cream does not always work and that he has not seen a dentist. On 07/10/24 at 12:40 PM, the resident reported that he has a few teeth left and that one on the bottom has a hole and that one on top was cracked. The resident reported that other than his usual body pain he constantly has mouth pain. The resident reported that he has trouble eating and has to cut everything up small. The resident reported that his dental pain is at a level of 7 to 8 and that all staff give him a cream to rub on his teeth that does not work. The resident reported that the medication he takes for his general pain does not work for his mouth pain. Review of Resident #21's admission Record revealed the most recent admission date was 5/28/24 with diagnoses to include Ataxia, Chronic Obstructive Pulmonary Disease and Hyperlipidemia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating cognitively intact. Review of the dental section revealed resident was marked as having none of the above issues to include obvious or likely cavity or broken natural teeth, inflamed or bleeding gums or loose natural teeth, and mouth or facial pain, discomfort or difficulty chewing. Review of the Social Service Progress Note dated 7/2/24 10:38 revealed Short Term resident is complaining of tooth pain, a referral has been sent to an outside provider. Review of the Social Service Progress Note dated 7/3/24 08:07 revealed the following: F/U [follow up] from dentist. Hi there, thank you for your email we are happy to see the patient. We accept cash or credit. We do not take Medicaid though. Thank You. Social Service Director (SSD) spoke with resident who expressed having no money, just cancel. This writer called leaving voice message for spouse, awaiting call back. Social Services will continue to assist. Interview on 07/10/24 at 1:15 PM with the SSD revealed the resident was not on a list for dental services. He reported that the resident had 3 teeth. The SSD reported that due to insurance concerns he scheduled an appointment for the resident at a dentist located down the road, but the resident did not go to the appointment because he would have to pay for the services. Interview on 07/11/24 at 9:33 AM with the MDS Coordinator/Licensed Practical Nurse (LPN) revealed the resident should have been coded differently as the coding was not accurate. She reported when doing the assessment, she actually takes a look at the resident's mouth and was aware of the broken teeth from the resident interview. She reported that every time the resident has an admission to the facility, the resident wants the facility to treat his dental concerns. A request was made of the facility to provide a policy related to accurate assessments. The facility did not provide the policy. 105644 Page 3 of 16 105644 07/11/2024 Aviata at Fletcher 518 W Fletcher Ave Tampa, FL 33612

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interviews, and record review, the facility failed to implement care plan interventions for one (#96) of 48 sampled residents, during four of four days (7/8/2024, 7/9/2024, 7/10/2024, and 7/11/2024). Findings included: Review of Resident #96's care plan revealed: The resident has an activity of daily living (ADL) self-care performance deficit related to disease process, impaired balance and limited mobility (date initiated: 10/8/23, date revised: 3/2/24). An intervention for this area included a heel protective boot to bilateral feet while in bed. May remove for ADL care (date initiated: 5/2/2024). The resident has potential for pressure injury development related to immobility (date initiated: 1/25/2024, date revised: 3/2/24). An intervention for this area included follow facility policies/protocols for the prevention/treatment of skin breakdown (date initiated 1/25/2024). The resident has peripheral vascular disease (PVD) related to diabetes and heart disease (date initiated and revised: 10/08/2023). An intervention for this area included elevate legs when sitting or sleeping (date initiated 10/08/2023). On 7/8/2024 at 10:45 a.m., Resident #96 was observed in his room asleep in bed. Observation of the box shelf on the wall above the television revealed two large protective heel boots. Resident #96 was noted not wearing these boots on either of his feet. Both feet were under bed linen and did not appear to be propped up on any type of pillow/device and no other splints, braces, or protective footwear were present on his feet. On 7/9/2024 at 7:45 a.m., 10:00 a.m., 1:45 p.m., and 3:10 p.m. Resident #96 was observed in bed, under the bed linen. The resident's protective soft boots were observed stored on the box shelf above the television during all observations. On 7/10/2024 at 8:04 a.m., Resident #96 was observed lying in bed. Resident #96 was not wearing the soft protective foot boots on his feet. The boots were still observed in place on the box shelving just above the television. Resident #96 was non-verbal but was able to respond to yes and no questions by shaking his head. Interview with Resident #96 confirmed he was supposed to wear his soft boots on his feet when in bed and did not have them on. No staff have offered to put the boots on for him. He would wear them if offered and does not refuse to wear the boots. He indicated staff do not help him put the boots on. The resident understood that the boots were to be worn to prevent pressure sores on his feet. The resident expressed having pain in his feet at the time of the interview, and the resident gave permission for the surveyor to view his feet. Observation of Resident #96's feet revealed they were bare and positioned on the bed mattress alone with no splints, pillows, or floating devices in place. On 7/10/2024 at 8:45 a.m., 10:15 a.m., 11:45 a.m., 1:00 p.m. and 2:15 p.m., Resident #96 was in bed with his entire body length under the bed linen. At 2:15 p.m., Resident #96 allowed this surveyor 105644 Page 4 of 16 105644 07/11/2024 Aviata at Fletcher 518 W Fletcher Ave Tampa, FL 33612

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to lift the sheets from his feet to make an observation. He was again observed not wearing any socks and both feet had no boots, pillows, or other devices to prop his feet on. Resident #96 confirmed he had not had any help putting his boots on today. He was asked if anyone attempted to assist him with the boots or offered the boots, and he shook his head in a no manner. Each observed time listed, the soft assistive heel boots were still on the wall shelf placed above the television and appeared to be undisturbed from the first observation made on 7/8/2024. On 7/11/2024 at 7:28 a.m., the resident could be seen in bed with the bed linen pulled up to his neck. Further observations revealed he was not wearing either of his soft protective boots while in bed. The boots were observed in the shelf area, directly on the wall above the television. On 7/11/2024 at 7:30 a.m., Staff I, Licensed Practical Nurse (LPN) said she was going to hang the resident's tube feeding and find out about the boots. On 7/11/2024 at 8:30 a.m., Resident #96 was observed in bed with his eyes open. The resident was wearing both protective heel boots. The resident expressed that staff assisted with placement of the boots. On 7/11/2024 at 9:45 a.m. an interview with Staff C, Certified Nursing Assistant (CNA) revealed she was a floating CNA but had the resident on her assignment many times before. She revealed that she provides activities of daily living (ADL) care, while he was usually receiving his tube feeding supplement. Staff C was asked if the resident utilized any splints or positioning devices and she revealed that he did not. She was asked if he wore any soft positioning boots and then she remembered that he did. Staff C revealed that it was usually direct care staff's responsibility as well as the restorative nurse to place the boots on when he was in bed. She did confirm at the beginning of the shift the boots were not on and that they were now. Staff C said Resident #96 had refused or taken the boots off and threw them on the floor in the past. She revealed if that happens during her shift, she reported it to the nurse. Staff C was unsure if the resident was care planned for behaviors of taking off or refusing use of the boots. On 7/11/2024 at 10:00 a.m., an interview with Staff D, LPN/Restorative Nurse revealed she was familiar with the resident. She verbalized Resident #96's orders for exercises and use of weights for range of motion (ROM) exercises and also confirmed he uses soft protective boots to wear at all times when he is in bed. She revealed it was the responsibility of all direct care staff to put the boots on, and not just restorative nursing staff. Staff D confirmed she put the boots on herself at around 8:15 a.m. today as he was not wearing them. Staff D confirmed she would have expected the boots would have been put on already, as he was in bed. She was not aware the boots had not been on the previous three days when observed in the bed. She revealed staff should know but there was no indication in the CNA [NAME] plan of care documentation of when to place the boots on. She also revealed that Resident #96 had at times refused, but she could not verify this though documentation. Staff D revealed she would need to talk to the nurse and care planning team each time he refused, in order for the team to come up with other interventions in order to make sure the boots are placed on while he was in bed. On 7/11/2024 at 10:20 a.m. an interview with Staff E, [NAME] Unit Manager confirmed Resident #96 utilized protective soft boots when in bed. She was unaware the boots were not offered and put on when observations were made on 7/8/2024, 7/9/2024, and 7/10/2024. She also revealed it was the direct care staff's responsibility to put the boots on when he is in bed. Staff E revealed that the boots were sometimes refused by the resident, but there was no documentation to support that. 105644 Page 5 of 16 105644 07/11/2024 Aviata at Fletcher 518 W Fletcher Ave Tampa, FL 33612

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the current Physician's Order Sheet dated July 2024 revealed an order for protective boots to bilateral feet while in bed. May remove for ADL care each shift (original order date 5/2/2024). Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for July 2024 revealed: protective boots to bilateral feet while in bed. May remove for ADL care every shift. (Start date 5/2/2024) - MAR/TAR documented for all ten days in July the resident had the protective boots on during the day and evening. Review of the quarterly Minimum Data Set (MDS) assessment, dated 6/4/2024, revealed a Brief Interview of Mental Status (BIMS) score of 11, indicating moderately impaired cognition, The resident was not documented as having any mood or behavior problems, and was marked as a yes for risk of pressure injury. Review of the nurse progress notes from 5/1/2024 - 7/11/2024 did not reveal any documentation indicating Resident #96 had ever refused or had a history of refusing to wear the protective boots while in bed. There were no notes that mentioned use of boots at all during this same timeframe reviewed. It was noted the current care plans did not have any problem areas, goals and interventions that reflect any type of behaviors of removing, resisting, or refusing the use of protective soft assistive boots prior to discussing with facility staff on 7/11/2024. Photographic evidence was obtained of the boots on the shelf. 105644 Page 6 of 16 105644 07/11/2024 Aviata at Fletcher 518 W Fletcher Ave Tampa, FL 33612

F 0694 Provide for the safe, appropriate administration of IV fluids 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 failed to provide care according to standards of practice related to an intravenous (IV) line, related to labeling of an IV line and accurate identification of the type of IV line for one resident (#264) out of one resident sampled for IV antibiotics. Residents Affected - Few Findings included: Review of Resident #264's admission Record revealed he was admitted to the facility on [DATE] from an acute care hospital with diagnoses to include urinary tract infection (UTI), artificial openings of urinary tract status, and sepsis due to Escherichia Coli (E. Coli). An interview and observation were conducted on 07/08/24 at 12:45 PM with Resident #264. Resident #264 was observed to be sitting on the side of the bed, clean, dressed in day clothes, without odors. Resident #264 was observed to have an intravenous (IV) pump in his room next to his bed. He said he has an IV in his right upper arm. He held his arm out and there was no date on the IV dressing and blood in the IV line. He said the last time the dressing was changed was Thursday (7/4/24) at the hospital. He said he was admitted to the facility on Friday (7/5/24). Review of Resident #264's BIMS [brief interview for mental status] Evaluation dated 7/8/24 revealed a BIMS score of 15 out of 15 indicating Resident #264 was cognitively intact. An observation and interview were conducted on 07/10/24 at 09:33 AM with Resident #264. He was observed to be walking with a cane around the facility. His IV line was observed to be in his right upper arm. The dressing was not intact. There was a piece of tape on his IV dressing dated 7/9/24 Resident #264 said they just put the tape with the writing on it this morning. Resident #264 stated they did not change the bandage. An interview and observation were conducted on 07/10/24 at 10:38 AM with Staff F, Registered Nurse (RN). She said when a resident was admitted to the facility with an IV, she looked at the label on the dressing to determine when the last time the dressings was changed. If the dressing was not changed the day the resident came to the facility, then the dressing is changed on admission. If the dressing was changed the day the resident was admitted to the facility, then the dressing gets changed every Sunday. Staff F, RN observed Resident #264's IV line dressing. The dressing was intact, and she confirmed it was dated 7/9/24 and signed by Staff G, RN, East Unit Manager (UM). An interview was conducted on 07/10/24 at 10:40 AM with Staff G, RN, East UM. She said she changed Resident #264's IV dressing, but she could not remember when she changed it and confirmed she did not document the dressing change. Review of Resident #264's Transfer Form from the Hospital to the Long Term Care Facility (Form 5000-3008) dated 7/2/24 revealed Section V. Treatment Devices: IV/PICC/Portacath Access-Date inserted: Type: Peripheral 7/2/24. Review of Resident #264's physician orders revealed an order with a start date of 7/5/24 and an end date of 7/11/24 for meropenem Intravenous Solution Reconstituted 1GM [gram], Use 1 gram intravenously every 8 hours for UTI for 5 days. Review of physician orders with a start date of 7/5/24 and no end date for IVs: Type of Access midline, IVs: Flush Mid Line [sic] with 10ml [milliliters] of normal 105644 Page 7 of 16 105644 07/11/2024 Aviata at Fletcher 518 W Fletcher Ave Tampa, FL 33612

F 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few saline every shift and as needed, IVs: Evaluate site for leakage/bleeding/signs of infection every shift. Further physician order reviews did not reveal an order to change Resident #264's midline IV dressing. Review of Resident #264's Admission/readmission Data Collection dated 7/6/24 revealed Resident admitted to the facility s/p [status post] hospitalization for an UTI. Resident is alert and oriented, ambulatory without assistance. Resident has a right nephrostomy tube draining clear amber urine, on IV antibiotics until 7/12/24. IV line clear and patent. Will continue to monitor. Review of Resident #264's July medication administration record (MAR) revealed Resident #264's physician order with a start date of 7/5/24 and no end date for IVs: Flush Mid Line [sic] with 10ml [milliliters] revealed no documentation on 7/8/24 for the 12 hour day shift. Resident #264's physician order with a start date of 7/6/24 for meropenem Intravenous solution reconstituted 1GM, use 1 gram intravenously every 8 hours for UTI for 5 days. Revealed the medication was given three times a day from 7/6/24 through 7/10/24. Review of Resident #264's care plans revealed a care plan created on 7/8/24 for [Resident #264] is on antibiotic therapy r/t [related to] infection. The goal revealed [Resident #264] will be free of any discomfort or adverse side effects of antibiotic therapy through the review date. The interventions included Administer antibiotic medications as ordered by physician. Monitor/document side effects and effectiveness Q-shift [every shift]. Monitor/document/report PRN [as needed] adverse reactions to antibiotic therapy: diarrhea, nausea, vomiting, anorexia, and hypersensitivity/allergic reactions (rashes, welts, hives, swelling face/throat). Monitor/document/report PRN s/sx [signs/symptoms] of secondary infection r//t [sic] antibiotic therapy: oral thrush (white coating in mouth, tongue). Persistent diarrhea, and vaginitis/itchy perineum/whitish discharge/coating of the vulva/anus. Report pertinent lab results to MD [medical doctor]. An interview was conducted on 07/10/24 at 12:05 PM with the Director of Nursing (DON). She said her expectation is IV dressings are to be clean, intact, and labeled with a date, time, and signature. She said IV dressing are to be changed weekly. She said when a resident is admitted , the IV dressing should be labeled and that is how the nurse can tell if the dressing was changed within the week. She said there should be physician orders in place to change a residents IV dressing. The DON reviewed the photographic evidence and confirmed the dressing was not labeled and she questioned if the IV was even a midline IV and she would have dug into that a little more. An interview was conducted on 07/10/24 at 01:34 PM with the DON. She said, she observed Resident #264's IV line, and she said the IV line was a peripheral line, not a midline, and if a resident was going to have antibiotics for longer than 3 days, she would have the peripheral line changed out for a midline. She said peripheral lines would still need dressing changes and confirmed there were no orders related to dressing changes. Review of the facility's Overview of IV Therapy policy revised 5/4/2020 revealed Infusion Equipment and Supplies: Labels - These may be preprinted with date, time, gauge, initials or can simply be a piece of tape that contains the same information. All tubing and dressings must have a label or they are considered to be out of date and should be changed. Photographic evidence was obtained. 105644 Page 8 of 16 105644 07/11/2024 Aviata at Fletcher 518 W Fletcher Ave Tampa, FL 33612

F 0790 Provide routine and 24-hour emergency dental care for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interview the facility failed to provide dental services in a timely manner for 1 of 48 (#21) sampled residents. Residents Affected - Few Findings Included: Review of Resident #21's record revealed this resident was re-admitted to the facility on [DATE] with diagnoses to include Ataxia, Chronic Obstructive Pulmonary Disease and Hyperlipidemia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating cognitively intact. Interview with Resident #21 on 07/08/24 at 03:38 PM revealed that he has had some toothache pain recently and that the facility puts cream on it. He reported that the cream does not always work and that he has not seen a dentist. During an interview with Resident #21 on 07/10/24 at 12:40 PM the resident reported that he has a few teeth left and one on the bottom has a hole and one on top was cracked. The resident reported that other than his usual body pain he constantly has mouth pain. The resident reported that he had trouble eating and had to cut everything up small. The resident reported that his dental pain was at a level of 7 to 8 (on a pain scale of 0-10), and staff give him a cream to rub on his teeth that does not work. The resident reported that the only other medication he receives for pain was for his general body pain does not work for mouth pain. Observations of the resident on 07/10/24 at 01:06 PM revealed that the resident received his mid-day meal tray which consisted of pork loin, lima beans, diced potatoes, dinner roll, and juice. The resident reported that he will dice his meat and potatoes very small, and he proceeded to do that. (Photographic evidence obtained) Review of the resident's physician orders revealed the following orders related to dental: Orajel 3 times a day for toothache & Gum mouth/throat gel 20-0.26, 1 application every 6 hours as needed for dental pain. Start date of 6/17/24. Oral Pain Relief Max St Gel 20% place and dissolve 1 application buccally [related to or located near the cheek or mouth cavity] every 8 hours as needed for mouth pain for 7 days. Start date was 6/24/24, and the end date was 7/1/24. Acetaminophen 325 mg (milligrams) 2 tabs every 6 hours as needed for mild pain. Do not exceed 3000 mg in 24 hours. Start date of 5/28/24. Dental as needed. Start date of 5/28/24. Review of Resident #21's care plan dated 1/22/24 revealed a focus care area related to oral/dental health problems related to poor oral hygiene with interventions that included monitor/document/report as needed any signs or symptoms of oral/dental problems needing attention (initiated 1/22/24). Review of section L (Oral/Dental Status) of the admission MDS dated [DATE] revealed that 105644 Page 9 of 16 105644 07/11/2024 Aviata at Fletcher 518 W Fletcher Ave Tampa, FL 33612

F 0790 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few sub-section D Obvious or likely cavity or broken natural teeth was left blank; sub-section E Inflamed or bleeding gums or loose natural teeth was left blank; sub-section F Mouth or facial pain, discomfort or difficulty chewing was left blank; and sub-section Z None of the above were present to indicate no dental concerns was checked. Review of the Social Service Progress Note dated 7/2/24 at 10:38 AM revealed Short Term resident is complaining of tooth pain, a referral has been sent to an outside provider. Review of the Social Service Progress Note dated 7/3/24 at 8:07 AM revealed the following: Follow-up from dentist. Hi there, thank you for your email we are happy to see the patient. We accept cash or credit. We do not take Medicaid though. Thank You. The Social Services Director (SSD) spoke with the resident who expressed having no money and told the SSD to cancel any appointment. This writer called leaving a voice message for spouse, awaiting call back. Social Services (SS) will continue to assist. Interview on 07/10/24 at 1:15 PM with the SSD revealed the resident is not on a list for dental. He reported that the resident had 3 teeth. The SSD reported due to insurance concerns, he scheduled an appointment for the resident at a dentist located down the road, but the resident did not go to the appointment because he would have to pay for the services. Interview on 07/11/24 at 9:16 AM with the SSD revealed that he was not aware of the resident's dental needs until 7/2/24 when the resident approached the SSD for dental care due to the resident seeing a dental vendor doing rounds in the building. He reported that typically residents are put on the dental list to be seen when they become Long Term Care (LTC) residents. Interview on 07/11/24 at 9:33 AM with the Licensed Practical Nurse (LPN)/MDS Coordinator revealed the resident's MDS was coded inaccurately and was aware of the broken teeth from interview with Resident #21. She reported that every time the resident had an admission to the facility, he wanted the facility to treat his dental concerns. Interview on 07/11/24 at 9:51 AM with Staff G, Registered Nurse (RN)/East Unit Manager revealed that she was familiar with Resident #21 and was told in June by the resident that he had toothache pain. She reported that she communicated this to the SSD to have the resident placed on the list to see the dentist but did not document the resident's toothache pain or communication to other departments. She reported that all new medications are reviewed at the morning meetings and the addition of the Orajel on 6/17/24 and the Benzocaine on 6/24/24 was discussed. She reported that she requested the resident be seen by the new dental vendor as no one was being seen by the previous vendor. She reported that the typical process was to talk to the primary physician to see if the resident can get some type of medication to ease the pain until he gets an appointment with the dental vendor. There was no documentation between 6/3/24 and 7/2/24 that would indicate the resident was provided with dental care from a dental vendor to address his dental concerns. Review of the facility policy titled Dentist Services with an effective date of 11/30/2014 and a revision date of 11/27/2017 revealed the following: If any resident of the facility is unable to pay for needed dental services, the facility will attempt to find alternative funding sources or alternative service delivery systems to ensure the resident maintains his/her highest practicable level of well-being. 105644 Page 10 of 16 105644 07/11/2024 Aviata at Fletcher 518 W Fletcher Ave Tampa, FL 33612

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, staff interviews and review of records, the facility failed to ensure one (dining room) of two ice makers used for residents was free from bio-growth. Residents Affected - Some Findings included: On 7/8/2024 at 12:30 p.m. and at 3:20 p.m. the main dining room was observed during the lunch meal dining service. The back wall area near the door leading to the kitchen was observed with a walled space containing a counter space, equipment storage area and a large ice maker. Observations revealed staff taking ice from the machine with an ice scoop. Further observations of the machine revealed heavy oxidation, calcification on the outside metal cover. When the ice machine door was opened, it was observed full with ice. Observations on the inner plastic ice chute revealed heavy black discoloration to include bio-growth spotting. It was determined this ice machine was used to serve ice to residents for consumption. On 7/9/2024 at 11:00 a.m., 2:00 p.m., 7/10/2024 at 7:30 a.m., 11:30 a.m., and 1:07 p.m., the dining room ice machine was again observed with black bio-growth in and surrounding the internal ice chute. On 7/11/2024 at 11:30 a.m., the Dietary Manager observed the dining room ice machine and confirmed the ice chute had black bio-growth spotted on it. The Dietary Manager was not sure who was responsible for cleaning this ice machine. Review of the policy titled Environment, with a revision date of 9/2017, revealed: All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition. The procedure section showed:: 1. The Dining Service Director will ensure the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation. 2. The Dining Services Director will ensure that all employees are knowledgeable in the proper procedures for cleaning and sanitizing of all food service equipment and surfaces. 3. All food contact surfaces will be cleaned and sanitized after each use. 4. The Dining Service Director will ensure that a routine cleaning schedule is in place for all cooking equipment, food storage areas, and surfaces. Photographic evidence was taken. 105644 Page 11 of 16 105644 07/11/2024 Aviata at Fletcher 518 W Fletcher Ave Tampa, FL 33612

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to administer medications in a clean and sanitary manner to prevent the spread of infection related to touching resident medications with bare hands for one resident (#36) out of six residents observed during the medication administration task. Residents Affected - Few Findings included: Review of Resident #36's physician orders revealed an order with a start date of 12/19/2018 and no end date for carbidopa-levodopa 25-100 milligram (mg), give one tablet by mouth five times a day for Parkinson's. A start date of 12/19/2018 and no end date for carbidopa-levodopa 50-200-200 mg give one tablet by mouth at bedtime for Parkinsons. A start date of 12/19/2018 and no end date for amlodipine besylate 5 mg, give 1 tablet by mouth one time a day for hypertension. A start date of 3/7/2019 and no end date for furosemide 20 mg, give one tablet by mouth one time a day every other day for fluid retention. A start date of 6/29/24 and no end date for multivitamin, give one tablet by mouth daily for supplement. A start date of 5/16/24 and no end date for clonazepam 0.5 mg, give one tablet by mouth two times a day for anxiety. A start date of 12/19/2018 and no end date for docusate sodium 100 mg, give one tablet by mouth two times a day for constipation. A medication administration observation was conducted on 07/11/24 at 11:47 AM for Resident #36 with Staff H, Registered Nurse (RN). She said this was her first day off orientation, but she has been a nurse at other facilities. She was observed to dispense the following medications in a medication cup. one tablet of carbidopa-levodopa 50-200-200 mg (milligram) one tablet of furosemide 20 mg one tablet of amlodipine besylate 5 mg Staff H, RN recognized she put the wrong dose tablet of carbidopa-levodopa in the medication cup so she removed the tablet out of the medication cup with her bare hands touching the other medication tablets with her hand and placed the tablet into the trash can attached to her medication cart. She then dispensed one tablet of carbidopa-levodopa 25-100 mg into the medication cup. She dispensed one tablet of multivitamin, one tablet of docusate sodium 100 mg, and one tablet of clonazepam 0.5 mg. Staff H, RN said the amlodipine pill broke in half. Half of the pill was observed to be on the medication cart and the other half was observed to be in the medication cup with the other tablets. Staff H, RN picked the piece of amlodipine tablet off her medication cart and then reached into the medication cup with her bare hands and removed the other piece, touching other medication tablets in the medication cup. She then discarded the medication into the trash can attached to the medication cart and dispensed a new 5 mg amlodipine tablet into the same medication cup. Staff H, RN entered into Resident #36's room and administered the medications to the resident. An interview was conducted immediately after the medication administration observation and Staff H, RN said she should not have used her bare fingers to remove the tablets from the medication cup. She also said she was told to trash the pills and not to put them down the toilet. On 7/11/24 at 1:30 p.m., the Director of Nursing (DON) said staff should not use their hands to remove pills from a medication cup, and staff should dispose of pills in the drug buster located in the 105644 Page 12 of 16 105644 07/11/2024 Aviata at Fletcher 518 W Fletcher Ave Tampa, FL 33612

F 0880 medication room. Level of Harm - Minimal harm or potential for actual harm An interview was conducted on 07/11/24 at 1:43 PM with the DON. She said the facility does not have a policy related to disposing of medications. Residents Affected - Few Review of the facility's Policies and Practices-Infection Control policy revised October 2018 revealed Policy Statement This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. Policy Interpretation and Implementation . 4. All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. The depth of employee training shall be appropriate to the degree of direct resident contact and job responsibilities . Review of the Centers for Disease Control and Prevention (CDC) guideline CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings dated 4/12/2024 revealed Introduction Adherence to infection prevention and control practices is essential to providing safe and high quality patient care across all settings where healthcare is delivered. .Core Practices Table .5c. Injection and Medication Safety References and Resources . 2. Use aseptic technique when preparing and administering medications. 105644 Page 13 of 16 105644 07/11/2024 Aviata at Fletcher 518 W Fletcher Ave Tampa, FL 33612

F 0926 Have policies on smoking. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to establish a policy to ensure a safe smoking area where protection from excessive heat and access to hydration was provided to nine of nine ( #13, #108, #30, #106, #165, #98, #19, #317, #166) residents identified as smokers. Residents Affected - Some Findings included: On 7/8/2024 the facility provided a Resident Smoking List which included Resident #13, #108, #30, #106, #165, #98, #19, and #166. Observations of the smoking patio from 7/8/2024 through 7/11/2024 revealed Resident #166 was also a smoker but was not included on the original list provided. Observations on 07/08/24 at 2:28 PM revealed approximately eight residents on the smoking patio. The smoking patio was noted to have no covered area to provide shade for the residents, who were observed to be lined up against the right side of the patio to get relief from the sun from the approximate 12 inches of shade created by the height of the building. Additional observations revealed there was no fluids to provide hydration. An interview was conducted at this time with Staff K, Certified Nursing Assistant (CNA). Staff K reported that she monitors the smoking patio. She reported that she brings out the cart with everyone's cigarettes, lighter and smoking aprons for those who need it. She reported that she brings nothing else out with her. During an interview with Resident #108 on 7/8/24 at 2:28 PM, the resident was observed against the right side of the wall smoking. Resident #108 stated liquids are not provided for residents on the smoking patio, but if they want to bring their own drink out; then they can. The resident reported he forgot his iced tea in his room and will have to drink it when he goes back in. The resident reported staff hold the cigarettes and the lighter and light the cigarettes for them. He reported that smoking times are six times a day and there is a two cigarettes max each time. Resident #108 reported they used to have umbrellas over the table, but over the years they got destroyed and were never replaced. Review of Resident #108's BIMS Evaluation, dated 5/9/24 revealed a score of 14, indicating cognitively intact. An observation of Resident #165 on 7/8/24 at 2:28 PM revealed the resident was actively smoking on the smoking patio against the right side of the wall under approximately one foot of shade provided by the height of the building. There was no other shade noted. Review of Resident #165's BIMS Evaluation, dated 6/21/24, revealed a score of 15, indicating cognitively intact. Review of [NAME], Florida weather history, at www.wunderground.com/history/daily/KTPA/date/2024-7-8, revealed on 7/8/24 at approximately 2:30 PM the temperature was 91 degrees Fahrenheit. During an interview on 7/9/24 at 9:14 AM the Activities Director revealed that each cigarette break is 15 minutes long and each resident gets a maximum of two cigarettes for each smoking session. She reported that she brings out the cart with the red boxes that contain each resident's cigarettes, one lighter and smoking aprons for those care planned to need the apron. She reported drinks are not provided on the patio, and the only shade provided was what the building makes. She reported there 105644 Page 14 of 16 105644 07/11/2024 Aviata at Fletcher 518 W Fletcher Ave Tampa, FL 33612

F 0926 is no fan or other cooling devices used for the smoking patio. Level of Harm - Minimal harm or potential for actual harm An observation on 7/9/24 at 10:27 AM revealed that smoking was in progress with approximately six residents on the patio. It was noted there was no shaded area and no fluids to provide hydration. Residents Affected - Some Review of [NAME], Florida weather history, at www.wunderground.com/history/daily/KTPA/date/2024-7-9, revealed on 7/9/24 at approximately 10:30 AM the temperature was 85 degrees Fahrenheit. An observation on 7/9/24 at 12:20 PM revealed that smoking was in progress with approximately six residents on the patio. It was noted there was no shaded area and no fluids to provide hydration. Resident #106, on 07/09/24 at 12:28 PM, was observed sitting along the right wall with approximately a foot of shade created by the height of the building. Continued observations revealed fluids were not offered to provide residents with hydration. During an interview with Resident #106 at this time, she reported liquids were not provided and that she finds shade wherever she can. Review of Resident #106's Brief Interview for Mental Status (BIMS) Evaluation, dated 6/20/24, revealed a score of 15, indicating cognitively intact. An observation of Resident #166 on 7/9/24 at 12:28 PM revealed the resident was on the smoking patio actively smoking. It was noted that there was no shade, and no fluids in the area. During an interview with Resident #166 at this time, Resident #166 stated liquids were not provided and there was no shade. Review of Resident #166's BIMS Evaluation, dated 7/9/24, revealed a score of 14, indicating cognitively intact. Review of [NAME], Florida weather history, at www.wunderground.com/history/daily/KTPA/date/2024-7-9, revealed on 7/9/24 at approximately 12:30 PM the temperature was 87 degrees Fahrenheit. An observation on 7/10/24 at 10:32 AM revealed approximately six residents on the smoking patio with smoking in progress. No fluids were observed on the patio to provide hydration, and the only shade present was approximately two feet of shade created from the height of the building on the left side of the courtyard. The residents were noted to be lined up against the left wall in order to be shaded from the sun. Review of [NAME], Florida weather history, at www.wunderground.com/history/daily/KTPA/date/2024-7-10, revealed on 7/10/24 at approximately 10:30 AM the temperature was 89 degrees Fahrenheit. An observation on 7/10/24 at 2:26 PM revealed approximately six residents on the smoking patio. The smoking patio was noted to have no covered area to provide shade and the residents were observed to be lined up against the right side of the patio to get relief from the sun from approximately 12 inches of shade created by the height of the building. Review of [NAME], Florida weather history, at www.wunderground.com/history/daily/KTPA/date/2024-7-10, revealed on 7/10/24 at approximately 2:30 PM the temperature was 92 degrees Fahrenheit. An observation on 7/10/24 at 4:04 PM of the smoking patio revealed approximately five residents outside who were about to start smoking. The patio was noted to have no shade, and the sky was alternating between overcast and sunny. Continued observations revealed no fluids on the patio to encourage 105644 Page 15 of 16 105644 07/11/2024 Aviata at Fletcher 518 W Fletcher Ave Tampa, FL 33612

F 0926 hydration. Level of Harm - Minimal harm or potential for actual harm Review of [NAME], Florida weather history, at www.wunderground.com/history/daily/KTPA/date/2024-7-10, revealed on 7/10/24 at approximately 4:00 PM the temperature was 91 degrees Fahrenheit. Residents Affected - Some During an interview on 7/10/24 at 4:10 PM with the Nursing Home Administrator (NHA), Director of Nursing (DON), and the Assistant Director of Nursing (ADON), the NHA confirmed there was no shade on the smoking patio. She reported Activities provides fluids if residents want it. The NHA, DON, and ADON could not verbalize how the residents would know they can get fluids while outside. An observation on 7/11/24 at 10:36 AM of the smoking patio revealed approximately five residents sitting under a small overhang by the door of the smoking patio with rain currently falling. Continued observations at this time revealed two maintenance staff members building a portable tent. While observing this, Resident #106, Resident #165, and Resident #166 were observed to come back inside from the smoking patio. Resident #106 said if it rains there is no smoking, and they never have water to drink on the patio, no fan, and no shade when it's hot. Resident #165 stated, This is crazy that there is no shade or fans for when it's hot. The resident reported if it rains they can't smoke. Resident #165 reported that if he wants something to drink while out in the heat smoking, he had to bring his own drink. Resident #166 stated if it rains there is no smoking, and usually there is no water on the patio, no fan and no shade. Review of [NAME], Florida weather history, at www.wunderground.com/history/daily/KTPA/date/2024-7-11, revealed on 7/11/24 at approximately 10:30 AM the temperature was 77 degrees Fahrenheit and raining. 105644 Page 16 of 16