Health inspection·January 25, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents were provided a clean and homelike environment (Photographic evidence obtained). Findings include: 1. During an observation on 1/22/2023 at 9:03 AM, a previously repaired portion of the ceiling was split opened and was detaching from the rest of the ceiling in the hallway in front the nursing station near room [ROOM NUMBER]. During an observation on 1/23/2023 at 10:00 AM a previously repaired portion of the ceiling was split opened and was detaching from the rest of the ceiling in the hallway in front the nursing station near room [ROOM NUMBER]. 2. During an observation on 1/23/2023 at 9:54 AM, in Resident #23's room, the air vent in the ceiling had a black substance on it. The air vent was located over the resident's bed. During an observation on 12/24/2024 at 11:35 AM, in Resident #23's room, the air vent in the ceiling had a black substance on it. The air vent was located over the resident's bed. 3. During an observation on 1/23/2023 at 9:58 AM, in Resident #16's room, the air vent in the ceiling had a black substance on it. The air vent was located over the resident's bed. During an observation on 1/24/2024 at 11:35 AM, in Resident #16's room, the air vent in the ceiling had a black substance on it. The air vent was located over the resident's bed. During an interview on 1/24/2024 at 11:35 AM, while conducting a tour with the Administrator, she confirmed the observed physical environment concerns and stated that they need to be taken care of. Review of the facility policy and procedure titled Cleaning and Disinfecting Resident's Rooms last review on 10/04/2023revised in August 2013, reads, Purpose: The purpose of this procedure is to provide guidelines for cleaning and disinfecting residents' rooms. General Guidelines: 1. Housekeeping surfaces (e.g. floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. 2. Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g. daily, three times per week) and when surfaces are visibly soiled. Page 1 of 14 105718 105718 01/25/2024 Aviata at Central Park 702 S Kings Ave Brandon, FL 33511

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary care and services related to nail care, for 3 (Resident #48, #66, #88) of 8 residents out of a total sample of 39 residents. Residents Affected - Few Findings include: 1. During an observation on 1/22/2024 at 9:50 AM, Resident #48's toenails of both feet were long and untrimmed. During an interview on 1/22/2024 at 9:50 AM, Resident #48's stated, I asked about cutting my toenails about a month ago and nobody has taken care of it. During an observation on 1/23/2024 at 2:30 PM, Resident #48's toenails of both feet were long and untrimmed. During an interview on 1/23/2024 at 2:30 PM, the resident stated, The toenails are the same. Somebody special needs to come and nobody has come. During an observation on 1/24/2024 at 8:09 AM, Resident #48 had long and untrimmed toenails. Review of the admission record for Resident #48 showed the resident was admitted on [DATE] with the diagnoses including nontraumatic intracerebral hemorrhage in cerebellum, nontraumatic subarachnoid hemorrhage from unspecified intracranial artery, other cerebral infarction due to occlusion or stenosis of small artery, benign neoplasm of meninges, and type 2 diabetes mellitus with hyperglycemia. Review of Resident #48's Minimum Data Set (MDS) Medicare 5-Day assessment dated [DATE] under Section GG - Functional Abilities and Goals documented the resident needed partial/moderate assistance for self-care related to showering/bathing. Review of care plan dated 12/11/2023 reads, Focus: [Resident #48's name] has an ADL self-care performance deficit r/t [related to] impaired balance. Date Initiated: 12/08/2023. Goal: [Resident #48's name] will improve current level of function in ADLs through the review date. Interventions: - Bathing/ Showering: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. 2. During an observation on 1/23/24 at 8:53 AM, Resident #88 had long and untrimmed toenails. During an interview on 1/23/24 at 8:53 AM, Resident #88 stated, My toenails are long and need to be cut. I can't reach them. I don't know who does that here. During on observation on 1/24/2024 at 8:15 AM, Resident #88 had long and untrimmed toenails. During an observation on 1/24/2024 at 10:51 AM with Staff E, Registered Nurse (RN), it was confirmed Resident #88's toenails were long and untrimmed. Review of Resident #88's MDS Medicare 5-Day assessment dated [DATE] Section GG - Functional 105718 Page 2 of 14 105718 01/25/2024 Aviata at Central Park 702 S Kings Ave Brandon, FL 33511

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Abilities and Goals documented the resident required substantial maximal assistance for self-care related to showering/ bathing. Review of Resident #88's care plan dated 12/22/2023, reads, Focus: [Resident #88's name] has an ADL self-care performance deficit r/t impaired balance, musculoskeletal impairment, and s/p [status post] surgery. Date Initiated: 01/02/2024. Goal: [Resident #88's name] will improve current level of function in ADLs through the review date. Date Initiated: 01/02/2024. Interventions: Bathing/Showering: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. During an Interview on 1/24/2024 at 11:33 PM, the Director of Nursing (DON) stated that her expectation from the staff was to provide care according to the care plan. During an interview on 1/24/2024 at 1:30 PM, the Social Services Director stated that the podiatry company comes twice a month. [Resident #48's name] and [Resident #88's name] were not on podiatry services and he was not aware why the residents were not on podiatry services. 3. During an observation 1/23/2024 at 9:26 AM, Resident #66 had long untrimmed fingernails. The fingernail beds had a yellow substance underneath. During an observation on 1/24/2024 at 8:11 AM, Resident #66 had long untrimmed fingernails with a yellow substance under the fingernail beds. Review of the admission record for Resident #66 showed the resident was admitted on [DATE] with the diagnoses included severe dementia without behavioral disturbance. Review of Resident #66's MDS Medicare 5-Day assessment dated [DATE] documented a BIMS (Brief Interview for Mental Status) score of 3 of 15 [indicating severe cognitive impairment] under Section C. Cognitive Patterns. Section GG. Functional Abilities and Goals documented the resident requires partial/moderate assistance for self-care related to showering/bathing. Review of Resident #66's care plan dated 1/23/2024, reads, Focus: [Resident #66's name] has an ADL self-care performance deficit r/t Activity Intolerance, Dementia, Fatigue, Limited Mobility. Date Initiated: 10/24/2023. Goal: Will improve current level of function in ADLs through the review date. Date Initiated: 10/24/2023. Interventions . - Bathing/ Showering: requires (mod. [moderate] assistance by 1) staff for bathing and grooming daily and showers per weekly schedule and as necessary. During an interview on 1/24/2024 at 10:25 AM, Staff E, Licensed Practical Nurse (LPN), confirmed that the resident had long, untrimmed, fingernail, and there was a yellow substance underneath the nail beds. During an interview on 1/24/2024 at 1:30 PM, the Social Services Director stated that the Podiatry company twice a month and the resident was not on podiatry services, and he was not aware why the resident was not on podiatry services. 105718 Page 3 of 14 105718 01/25/2024 Aviata at Central Park 702 S Kings Ave Brandon, FL 33511

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, record review and policy and procedure review the facility failed to provide care for peripherally inserted central catheters in accordance with professional standards of practice for 1 out of 2 residents, Resident #88, out of a total sample of 39 residents. Residents Affected - Few Findings include: During an observation on 1/25/2024 at 12:45 PM of medication administration for Resident #88 Staff E, Registered Nurse (RN) did not perform hand hygiene, donned gloves, locked the medication cart with one of her gloved hands, knocked on Resident #88's room door with one of her gloved hands and entered Resident #88's room. Resident #88 was observed in bed with a right upper arm double lumen PICC line (peripherally inserted central catheter). Staff E touched items on Resident #88's overbed table and placed supplies on the resident's dresser with her gloved hands. Staff E did not remove the gloves, did not perform hand hygiene, and opened an intravenous (IV) tubing package and connected the IV tubing to an IV bag of antibiotics. Staff E removed the end cap from the tubing and primed the tubing leaving the end of the tubing uncapped and hung the tubing on the IV pole. The uncapped end of the IV tubing was observed touching the IV pole. Staff E then scrubbed the needleless connector for less than three seconds, did not check for blood return and flushed the needleless connector with 5 milliliters of normal saline. Staff E scrubbed the second needleless connector for less than two seconds and without verifying for blood return flushed the remaining 5 milliliters into the second needleless connector. Staff E doffed the gloves and donned a new set of gloves without performing hand hygiene and attached the IV tubing to the needleless connector. During an interview on 1/25/2024 at 12:58 PM Staff E, RN stated, I did not wash my hands when I changed my gloves, I should have. I shouldn't have put my gloves on before I went into the room. I should not have uncapped the IV tubing when I primed the tubing. I didn't realize that it was touching the IV pole. I didn't realize that I couldn't use the same normal saline flush for both of them. I don't know if the order is for 5 or 10 milliliters. I didn't verify the placement before I flushed it. I did not verify, and I should have done that. I should have taken more time cleaning the connectors. During an interview on 1/25/2024 at 1:30 PM the Director of Nursing stated, I expect staff to complete hand hygiene and flush PICCs according to doctor orders. She should have verified placement of the PICC line before giving the saline. She should not have used the same syringe for both sides. The orders are for 10 ml (milliliter) flushes. Review of the admission record for Resident #88 documented diagnosis which include psoas muscle abscess [a collection of pus in the psoas muscle of the spine], discitis [an inflammation or infection in the cushion spaces between each part of the spine], paroxysmal atrial fibrillation [an irregular heart beat], anemia, acute embolism and thrombosis of deep vein of left upper extremity [blood clot], idiopathic peripheral autonomic neuropathy [nerve damage], unspecified glaucoma, major depressive disorder, and vertebral osteomyelitis [severe bone infection in the spine]. Review of the physician order for Resident #88 dated 12/21/2023 reads, Normal s Saline Flush Intravenous Solution 0.9% (Sodium Chloride Flush) Use 10 ml (milliliters) intravenously every shift for iv (intravenous) abt (antibiotic). 105718 Page 4 of 14 105718 01/25/2024 Aviata at Central Park 702 S Kings Ave Brandon, FL 33511

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the physician order for Resident #88 dated 12/21/2023 reads, Cefazolin Sodium Intravenous Solution Reconstituted 2 GM (grams) (Cefazolin Sodium) Use 2 gram intravenously every 6 hours for sepsis/abscess until 01/31/2024. Review of the policy and procedure titled Flushing and Locking Central Vascular Access Device ( CVAD) last review 10/04/2023, reads, Policy: 4. Flushing/locking is performed to ensure and maintain catheter patency and to prevent the mixing of incompatible medications/solutions. 5. Needleless connectors require vigorous cleaning with alcohol prior to accessing to reduce the risk of catheter related bloodstream infections. 6. Licensed nurses caring for patients receiving infusion therapies are expected to follow infection control and safety compliance procedures. General Guidelines. 5. Catheter patency must be verified prior to each access. To assess patency, aspirate the catheter to obtain positive blood return. The aspirated blood should be the color and consistency of whole blood. 8. Single use flushing/locking systems must be used. Procedure. 4. Perform hand hygiene. 6. [NAME] gloves. 7. Vigorously cleanse needleless connector with alcohol. Allow to air dry. 9. Attach syringe filled with prescribed flushing agent to needleless connector. Aspirate the catheter to obtain positive blood return to verify vascular access patency. 105718 Page 5 of 14 105718 01/25/2024 Aviata at Central Park 702 S Kings Ave Brandon, FL 33511

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews the facility failed to administer oxygen per physician's orders and according to professional standards of practice for 2 of 3 residents reviewed for respiratory care (Resident #5 and #27) out of a total sample of 39 residents. Residents Affected - Few Findings include: During an observation on 1/22/2024 at 10:26 AM, Resident #5 was observed resting in bed receiving oxygen via nasal cannula. The oxygen concentrator was set at 4 liters. During an observation on 1/23/2024 at 7:27 AM, Resident #5 was sitting in bed with the head of bed elevated receiving oxygen via nasal cannula. The oxygen concentrator was running at 4 liters per minute. The oxygen concentrator was on her right side of the bed pushed against the wall out of the resident's reach. During an interview on 1/23/2024 at 7:27 AM Resident #5 stated, I can't reach the oxygen machine to change it. I don't have the strength to reach that far. During an observation on 1/24/24 at 7:15 AM, Resident #5 was resting in bed with the head of the bed elevated, receiving oxygen via nasal cannula. The oxygen concentrator was set at 4 liters per minute. The oxygen concentrator was on the right side of the resident's bed, against the wall at the head of her bed, out of residents reach. During an observation on 1/24/2024 at 7:16 AM with Staff I, Registered Nurse (RN) verified that oxygen was running at 4 liters nasal cannula and that oxygen concentrator was not within the resident's reach. During an interview on 1/24/2024 at 7:16 AM Staff I, RN, stated, This resident [Resident #5] doesn't play with her oxygen, she can't reach the oxygen tank to change it. It [the oxygen concentrator] is too far from her for her to reach it. I did not verify what the oxygen was running at, and we should do that every day. During an interview on 1/24/2024 at 8:10 AM the Director of Nursing (DON) stated, The staff should check the amount of oxygen a resident is getting at least when they are passing medications. Oxygen is considered a medication, and they should verify this. Review of the admission record for Resident #5 documented diagnosis which included chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus, unspecified combined systolic (congestive) and diastolic (congestive) heart failure (CHF), personal history of pulmonary embolism [a blood clot in the lungs], and unspecified atrial fibrillation [an irregular heartbeat]. Review of the physician's orders dated 12/8/2023 read, Respiratory: Oxygen 2 liters continuous every shift related to COPD. Review of the comprehensive resident centered care plan for Resident #5 revised on 1/4/2019 reads [Resident #5's Name] is at risk for ineffective gas exchange r/t (related to) COPD, O2 (Oxygen) therapy. Goal. Will have no s/sx (signs and symptoms) of poor oxygen absorption. Interventions. Oxygen 105718 Page 6 of 14 105718 01/25/2024 Aviata at Central Park 702 S Kings Ave Brandon, FL 33511

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few settings: O2 as ordered. [Resident #5's Name] has potential for altered respiratory status/difficulty breathing r/t COPD, CHF. Goal. [Resident #5's Name] will maintain normal breathing pattern as evidenced y normal respirations, normal skin color, and regular respiratory rate/pattern. Interventions. Administer medications/puffers as ordered. Review of the policy and procedure titled, Oxygen Therapy last reviewed 10/4/2023, reads, Policy: Oxygen therapy is the administration of a FiO2 [Fraction of Inspired Oxygen; it is the amount of oxygen a patient is inhaling produced by an oxygen device] greater than 21% by means of various administration devices to: raise the residents PaO2 [partial pressure of oxygen; the oxygen pressure in arterial blood] to an acceptable baseline, to treat arterial hypoxemia, to decrease the work of breathing, to reverse and prevent tissue hypoxia and/or to decrease myocardial workload. Procedure: Review physicians order, , start O 2 flowrate at prescribed liter flow or appropriate liter flow for administration device. Review of the policy and procedure titled, Medication preparation for administering, last review on 10/4/2023, reads, Policy: All medications will be prepared and administered in a manner consistent with the general requirements outlined in this policy. Procedure: D. Medication Inspection: 1. Confirm the medication name and dose are correct. G. Prior to medication administration: 1. Verify each medication preparation that the medication is the right drug, at the right dose, the right route, at the right rate, at the right time, for the right customer. 2. During an observation on 1/22/2024 at 3:34 PM, Resident #27 was observed sitting in bed with the head of bed elevated with oxygen infusing via nasal cannula. The oxygen concentrator was set a 3 liters per minute. During an observation on 1/23/2024 at 9:19 AM, Resident #27 was observed in bed with the head of the bed elevated with oxygen infusing via nasal cannula. The oxygen concentrator was set at 3.5 liters. During an observation on 1/24/2024 at 7:12 AM Resident #27 was observed in bed with oxygen infusing via nasal cannula. The oxygen concentrator was set at 3.5 liters. During an interview on 1/24/24 at 7:12 AM, Staff I, RN verified that Resident #27's oxygen was running at 3.5 liters. During an interview on 1/24/2024 at 7:12 AM Staff I, RN stated, Her [Resident #27's oxygen] orders are for 2 liters. I did not have any change in condition last night. I did not verify what her oxygen was running at last night. We should complete this [verify oxygen administration] when we are administering meds [medications] and doing our checks. Review of the admission record for Resident #27 documented diagnosis which included acute respiratory failure with hypercapnia, pneumonia unspecified organism, chronic obstructive pulmonary disease, type 2 diabetes mellitus, unspecified combined systolic and diastolic heart failure, chronic ischemic heart disease, hypertensive heart and chronic kidney disease with heart failure, and chronic kidney disease stage 2. Review of the physician's orders for Resident #27 dated 12/7/2023 reads, Respiratory: Oxygen-continuous 2 LPM (liters per minute) every shift. 105718 Page 7 of 14 105718 01/25/2024 Aviata at Central Park 702 S Kings Ave Brandon, FL 33511

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the nursing progress notes from 1/18/2024 through 1/22/2024, there were no progress notes or change of condition notes within the medical record. Review of the comprehensive resident centered care plan for Resident #27 initiated 5/08/2023 reads [Resident #27's Name] has oxygen therapy r/t ineffective gas exchange Goal. [Resident #27's Name] will have no s/sx of poor oxygen absorption. Interventions. Oxygen settings: O2 via nasal cannula as ordered. [Resident #27's Name] has potential for altered respiratory status/difficulty breathing r/t Sleep Apnea, COPD, CHF, and c/o (complaints of) SOB (shortness of breath) and wheezing at times. Goal. [Resident #27's Name] will maintain normal breathing pattern as evidenced by normal respirations, normal skin color, and regular respiratory rate/pattern. Interventions. Administer medications/puffers as ordered. 105718 Page 8 of 14 105718 01/25/2024 Aviata at Central Park 702 S Kings Ave Brandon, FL 33511

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and policy and procedure review the facility failed to label and store all medications in accordance with professional standards of practice for 3 of 4 medication carts, and failed to ensure all medications were stored to permit only authorized personnel access. Findings include: 1. During an observation on 1/22/24 at 8:46 AM with Staff A, Licensed Practical Nurse (LPN) of medication cart #1, there was one unopened Lantus insulin pen with pharmacy instructions to refrigerate until opened, one opened insulin glargine pen with no resident identifier, not in original pharmacy packaging, with no date opened, or expiration date, one opened bottle of Lispro insulin with no date opened or expiration date, one unopened bottle of Aspart insulin with pharmacy instructions to refrigerate until opened, and two opened bottles of tobramycin ophthalmic solution with no date opened or expiration dates. During an interview on 1/22/2024 at 8:50 AM Staff A, LPN stated, I don't know why they [the insulins] are not refrigerated, and all medications should be in the original pharmacy package for the resident and should have when they were opened or expire. Eye drops should be labeled. 2. During an observation on 1/22/2024 at 8:54 AM of medication cart #2 showed there was no staff present at the medication cart. Staff B, LPN returned to the medication cart after three minutes, unlocked the cart, and opened the top drawer. In the top drawer there was a medication cup containing ten medications, the cup was not labeled with a resident identifier, the medications, or who prepared the medications. There was one unopened Levemir insulin pen with pharmacy instructions to refrigerate until opened, one unopened Lantus insulin pen with pharmacy instructions to refrigerate until opened, and one opened bottle of Levemir insulin with no date opened or expiration date. During an interview on 1/22/2024 at 9:00 AM Staff B, LPN stated, I should not have pre poured the medication, but I just had to walk away from the cart. They should be labeled if I walk away. All insulins should be labeled when opened and kept in the refrigerator until its opened. 3. During an observation on 1/22/24 at 9:15 AM with Staff C, Registered Nurse (RN) of medication cart #4, there was one opened bottle of Latanoprost ophthalmic solution with no date opened or expiration date, one opened bottle of Timolol ophthalmic solution with a date opened of 12/9/2023, one opened bottle of Prednisolone ophthalmic solution with no date opened or expiration date, one opened bottle of Timolol ophthalmic solution with no date opened or expiration date, one opened bottle of Timolol ophthalmic solution with an expiration date of 12/31/2023, one opened bottle of Lumigan ophthalmic solution with an expiration date of 12/23/23, one opened Lispro insulin pen with an expiration date of 12/12/23 and labeled with pharmacy instruction to store using direction provided: Throw away any medication that remains 28 days after first use; one opened Novolin insulin pen with an expiration date of 1/6/2024, one opened Novolog pen with an expiration date of 12/28/2023, one opened Humalog pen with an expiration date of 1/13/2024, one opened Humalog pen with an expiration date of 1/13/2024, one opened Lantus pen with no date opened or expiration date, and one opened bottle of Levemir with no date opened or expiration date. During an interview on 1/22/2024 at 9:25 AM Staff C, RN stated, What can I say, all expired meds 105718 Page 9 of 14 105718 01/25/2024 Aviata at Central Park 702 S Kings Ave Brandon, FL 33511

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some [medications] should not be on the cart they should have been thrown out. Everything the insulin and eye drops should be labeled when they are opened or when they are expiring. During an interview on 1/22/2024 at 1:55 PM the Director of Nursing stated, All expired medications should not be on the cart. All insulin and eye drops should have the date opened or expiration date on them. No meds should be pre-poured. Review of the Policy and Procedure titled, Medication Storage last revied on 10/4/2023 read, Policy: Medications will be stored in a manner that maintains the integrity of the product and ensures the safety of the residents and is in accordance with the FL [Florida] Department of Health guidelines. Procedure: E. Medications will be stored in the original, labeled containers received from pharmacy. F. Expired, discontinued and/or contaminated medications will be removed from the medication storage areas and disposed of in accordance with facility policy. G. Medications will be stored at appropriate temperature in accordance with the pharmacy and/or manufacturer labeling. Appropriate temperature will be determined as per the following: 3. Cold Place: 2-8 degrees Celsius (36-46 degrees F [Fahrenheit]. H. Medications requiring refrigeration will be stored in a refrigerator that is maintained between 2-8 degrees Celsius (36-46 degrees F). If a medication label indicates to store in a cool place, the medication will be stored in the refrigerator unless specifically noted otherwise. 4. During an observation on 1/22/24 at 09:30 AM of Resident #86 it showed she was sitting in bed and there was a bottle of Voltaren gel on her over the bed table. During an observation on 1/23/24 at 08:30 AM of Resident #86 it showed she was laying in her bed and a bottle of Voltaren Gel was on her over the bed table. During an interview on 1/23/24 at 8:30 AM Resident #86 stated, I bought that online, and the staff are supposed to help me put it on my knees every 6 hours. Review of the physician's orders dated 12/28/23 read, Voltaren External Gel 1% (diclofenac sodium topical) Apply to knees topically every day shift for mild pain. During an interview on 1/24/24 at 10:00 AM the Regional Director of Clinical Services stated the residents must be assessed for self-administration to be able to have medications at their bedside. During an interview on 1/24/24 at 10:05 AM the Director of Nursing stated, Resident #86 has not had an assessment for self-medication, and there should be no medications left at her bedside. If she is capable of self-medication, we will get her a lock box where she can keep the Volteran gel. The Director of Nursing, stated resident #86 is not care planned for self-administration of medications. 105718 Page 10 of 14 105718 01/25/2024 Aviata at Central Park 702 S Kings Ave Brandon, FL 33511

F 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. Based on interview and record review the facility failed to promptly notify the ordering physician of urine culture results requiring a change in treatment for 2 of 3 residents, Residents #31 and #84, in a total sample of 39 residents. Findings include: Review of the admission record for Resident #31 documented diagnosis to include paroxysmal atrial fibrillation (an irregular heartbeat), urinary tract infection, hypertensive heart disease without heart failure and gastroesophageal reflux disease. Review of the nursing progress note for Resident #31 dated 1/15/2024 read, Resident went to infectious disease appointment today, new order received from ID [infectious disease] doctor for CBC [complete blood count], CMP [complete metabolic profile], lipase, procalcitonin, U/A [urinalysis], C&S [urine culture and sensitivity] daughter aware. Review of the physician orders for Resident #31 dated 1/16/2024 read, U/A with micro C&S [culture and sensitivity] one time. Review of the lab results completed by [name of the laboratory group] for Resident #31 read, 1/17/2024 13:57 [1:57 PM] Comprehensive Panel/Lipase/CBC w/o Diff [differential]/Procalcitonin. Procalcitonin Result 0.670 ng/mL, Ref. [Reference] Range <0.100, Flag H [high]. Interpretation Guidelines >= 0.5 to <2.00 ng/mL [nanograms per millilitre]: Sepsis is possible; other conditions possible. WBC [white blood cell] Result 12.5, Flag HIGH, Referent Range/Cutoff 3.8 - 10/8. Review of the lab results completed by [name of the laboratory group] for Resident #31 read, Collection date 1/18/2024 3:39 AM, received date 1/18/2024 at 8:52 AM, originally reported on: 1/20/2024 11:30 AM, Urine culture: Organism Escherichia coli, Colony count: >100,00 cfu [colony forming units]/ml [milliliter]. Review of the physician orders for Resident #31 dated 1/22/2024 at 8:43 AM read, Cipro oral tablet 500 mg (Ciprofloxacin HCL) Give 1 tablet by mouth two times a day for UTI [urinary tract infection] for 5 days. During an interview conducted on 1/24/2024 at 9:58 AM the Director of Nursing (DON) verified the urine culture results were provided to the facility on 1/20/2024, there was no physician notification documented in the medical record, and no orders documented to treat Resident #31 for a UTI until 1/22/2024. The DON stated, This should have been called on 1/20 when we received the results. We should have notified the physician or ARNP [Advance Registered Nurse Practitioner] and gotten orders for the antibiotic then. It is my expectation that staff call culture results immediately. During an interview conducted on 1/24/2024 at 1:15 PM Staff C, Registered Nurse (RN) stated, I saw her [Resident #31] culture results on Monday morning. When I came on Monday, I looked for the results, but we should have called before Monday to get it [the UTI] treated. When it came in is when we should call [the physician]. During a telephone interview on 1/25/2024 at 9:00 AM the Medical Director (MD) stated, I fully 105718 Page 11 of 14 105718 01/25/2024 Aviata at Central Park 702 S Kings Ave Brandon, FL 33511

F 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some expect staff to call immediately with any urine culture reports so that we may begin treatment. I was not notified in a proper amount of time. I should have been notified when the lab report was provided to the facility on 1/20. Given her elevated WBC, and elevated PCT [procalcitonin], she could have developed sepsis from the UTI. But ultimately she did not have any harm. During a telephone interview on 1/25/2024 at 1:35 PM Staff J, Registered Nurse stated, I really can't remember if I was aware of the C&S results for her [Resident #31]. They will come across the fax machine when they are completed. I should have checked the culture results and called them to the doctor for treatment. I can't tell you why I didn't. Review of the policy and procedure titled, Notification of Change in Condition revision date of 12/16/2020, last approval date of 10/4/2023 read, Policy: The Center to promptly notify the patient/resident, the attending physician, and the resident representative when there is a change in the condition or status. Procedure: The nurse to notify the attending physician and resident representative when there is a (n): Need to alter treatment significantly, new treatment. The nurse will contact the physician. In the event that the attending physician does not respond in a reasonable amount of time, the Medical Director may be contacted. 2. Review of the admission record for Resident #84 documented diagnosis that include cerebral Infarction (a stroke), secondary neoplasm of brain (brain cancer), malignant neoplasm of unspecified part of unspecified bronchus or lung (lung cancer), non-ST elevation myocardial infarction (a heart attack), anemia, and unspecified dementia. Review of the physician orders for Resident #84 dated 1/3/2023 read, UA, C&S one time only for 1 day. Review of the laboratory results report for Resident #84 dated 1/3/2024 read, Collection date 1/3/2024, received date 1/3/2024 08:42 reported date 1/5/2024 at 11:16 AM. Urine Culture: Organism: Klebsiella oxytoca 50,000-100,000 CFU/ml. Review of the physician orders for Resident #84 dated 1/8/2024 read, Ciprofloxacin HCL [hydrochloride] oral tablet 500 mg give 1 tablet by mouth two times a day for UTI for 5 days. During an interview on 1/25/2024 at 2:10 PM the DON stated, All culture results should be called when they are received. Her results were not called, and her UTI was not treated until 1/8/2024 and they should have been called when they came in on the 5th. 105718 Page 12 of 14 105718 01/25/2024 Aviata at Central Park 702 S Kings Ave Brandon, FL 33511

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 prevent the possible spread of infection during medication administration for 2 of 6 observations. Residents Affected - Few Findings include: 1. During an observation on 1/22/2024 at approximately 2:02 PM of medication cart #3, Staff, C, Registered Nurse (RN) did not perform hand hygiene and began preparing medications for Resident #84. Staff C opened the medication cart drawer, pulled the medication blister packs up but did not remove the medication blister packs out of the drawer and began to pop the medications into her bare hand, then placed them into the medication cup for a total of six medications. Staff C went to Resident #84's room and without performing hand hygiene administered the medications and returned to the medication cart. Staff C did not perform hand hygiene and began to prepare medications for another resident. During an interview on 1/22/2024 at 2:05 PM Staff C, RN stated, Oh, I didn't realize that I did that. I should not have put the medicine into my hand, they need [the medications] to go directly into the medicine cup. I should have used the hand sanitizer. Review of the policy and procedure titled Medication Preparation for Administering last reviewed 10/4/2023 read, Policy: All medications will be prepared (blister card, vials, Artromick box [mobil medical storage]) and administered in a manner consistent with the general requirements outlined in this policy. Procedure: A. Prior to preparing or administering medications, follow the facility's infection control policies (e.g. hand washing). B. Medication Dose Preparation: 4. Do not touch the medication when opening a bottle or unit dose package. 2. During an observation on 1/25/2024 at 12:45 PM of medication administration for Resident #88 Staff E, RN did not perform hand hygiene, donned gloves, locked the medication cart with one of her gloved hands, knocked on Resident #88's room door with one of her gloved hands and entered Resident #88's room. Resident #88 was observed in bed with a right upper arm double lumen PICC line (peripherally inserted central catheter). Staff E touched items on Resident #88's overbed table and placed supplies on the resident's dresser with her gloved hands. Staff E did not remove the gloves, did not perform hand hygiene, and opened an intravenous (IV) tubing package and connected the IV tubing to an IV bag of antibiotics. Staff E removed the end cap from the tubing and primed the tubing leaving the end of the tubing uncapped and hung the tubing on the IV pole. The uncapped end of the IV tubing was observed touching the IV pole. Staff E then scrubbed the needleless connector for less than three seconds, did not check for blood return and flushed the needleless connector with 5 milliliters of normal saline. Staff E scrubbed the second needleless connector for less than two seconds and without verifying for blood return flushed the remaining 5 milliliters into the second needleless connector. Staff E doffed the gloves and donned a new set of gloves without performing hand hygiene and attached the IV tubing to the needleless connector. During an interview on 1/25/2024 at 12:58 PM Staff E, RN stated, I did not wash my hands when I changed my gloves, I should have. I shouldn't have put my gloves on before I went into the room. I should not have uncapped the IV tubing when I primed the tubing. I didn't realize that it was touching the IV pole. I should have taken more time cleaning the connectors. During an interview on 1/25/2024 at 1:30 PM the Director of Nursing stated, I expect staff to 105718 Page 13 of 14 105718 01/25/2024 Aviata at Central Park 702 S Kings Ave Brandon, FL 33511

F 0880 complete hand hygiene. Level of Harm - Minimal harm or potential for actual harm Review of the policy and procedure titled Flushing and Locking Central Vascular Access Device (CVAD) last reviewed 10/4/2023 read, Policy: 5. Needleless connectors require vigorous cleaning with alcohol prior to accessing to reduce the risk of catheter related bloodstream infections. 6. Licensed nurses caring for patients receiving infusion therapies are expected to follow infection control and safety compliance procedures. Procedure: 4. Perform hand hygiene. 6. [NAME] gloves. 7. Vigorously cleanse needleless connector with alcohol. Allow to air dry. Residents Affected - Few 105718 Page 14 of 14