Health inspection·September 2, 2022

F 0571 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Limit the charges against residents' personal funds for items or services for which payment is made under Medicare or Medicaid. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain a written authorization for disbursements from the resident trust account for 1 of 1 resident reviewed for personal funds out of a total sample of 57 residents (#54). Findings: Resident #54's medical record revealed she was originally admitted to the facility on [DATE] and readmitted from an acute care hospital on 2/06/22. Her diagnoses included heart failure, type 2 diabetes, history of COVID-19, chronic kidney disease and dependence on renal dialysis. Review of the Minimum Data Set Quarterly Assessment with Assessment Reference Date of 7/05/22 revealed resident #54 had a Brief Interview for Mental Status score of 15 which indicated she was cognitively intact. Resident #54's medical record revealed she made all the decisions for her care. On 8/29/22 at 12:12 PM, resident #54 stated she learned from other residents they received $130.00 every month but that was not her case. Resident #54 explained she spoke with someone at the business office about a month ago and was told they would check on her account, but no one had returned to update her. On 8/31/22 at 3:59 PM, the Business Office Manager (BOM) stated he handled the resident trust accounts, collected payments, and printed out statements which were mailed to the residents or their responsible parties as required. The BOM explained the statements from the resident trust accounts were sent quarterly to the residents or the responsible party listed on the resident's medical record. He explained if the resident was also the responsible party, the statement was delivered to the resident's room by the Activities Director. The BOM confirmed resident #54 was approved for Medicaid on 8/26/21 and she would receive a standard monthly allowance of $130.00. The BOM explained resident #54 was not set up to receive her allowance because there was an agreement with the previous BOM to use the money towards an outstanding balance resident #54 had with the facility when she was under private pay. The BOM stated the account pre-dated him, and it appeared resident #54's allowance was being used to pay the balance owed to the facility. The BOM noted he did not find a signed written agreement from resident #54 authorizing the facility to take her monthly Medicaid allowance and apply it to the balance owed. The BOM confirmed he spoke with resident #54 about 3 weeks ago when she inquired about her Medicaid allowance. The BOM explained after he reviewed her account, he updated the resident about his findings and told her he was still working on trying to figure out what happened. The BOM concluded the $130.00 was applied to the balance owed and confirmed the $130.00 was not transferred to resident #54's trust account. The BOM stated this was not a practice he followed. The BOM Page 1 of 22 105985 105985 09/02/2022 Aviata at Palm Bay 5405 Babcock St NE Palm Bay, FL 32905

F 0571 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few confirmed the resident's statement was being mailed to her son's address instead of delivering it to her in the facility. The BOM confirmed he had not given resident #54 a copy of her statement when he spoke with her. The BOM did not know if resident #54 received her quarterly statements. On 8/31/22 at 5:26 PM, the Administrator stated she was not aware resident #54 was not receiving her $130.00 monthly allowance as required. On 9/01/22 at 10:24 AM, the Divisional Director of Business Office Services (DDBOS) explained the $130.00 was being applied to the resident #54's balance based on a verbal agreement between the former BOM with the family and the resident. The DDBOS stated the resident's trust account worked like a bank and residents should had signed a form authorizing this monthly transaction, but they did not have it. The DDBOS stated she did not have the answers as of why this was done this way. The DDBOS confirmed the facility had no evidence resident #54 or her family approved the use of her $130.00 monthly allowance. On 9/01/22 at 2:59 PM, the DDBOS confirmed the former BOM did not document the verbal agreement in resident #54's medical record. The DDBOS stated the facility did not have a copy of the financial agreement signed by the resident on admission. On 9/01/22 at 10:13 AM, resident #54 indicated she neither gave verbal authorization nor signed an agreement with the facility to take her monthly $130.00. She stated her son never mentioned she was getting any bills from the facility at his address, and she had not seen any statements or bills during her time there. Review of the facility policy Resident Trust Fund (RTF) - Resident Fund Withdrawal Tickets, revised on 10/2021, read, All disbursements made from the RTF must be documented with a properly signed withdrawal ticket. Review of the facility policy Resident Trust Fund - RTF Quarterly Statement, revised on 2/26/21, read, The BOM is responsible for ensuring that complete and correct addresses are in the computer system for all residents. The procedure included, A signed copy of in-house statements should be obtained as acknowledgement from all competent residents and filed with copies of mailed statements. Review of the Bill of Rights for Residents of Nursing Homes revealed long-term care residents had the right to manage their own financial affairs and be informed of the cost of services. 105985 Page 2 of 22 105985 09/02/2022 Aviata at Palm Bay 5405 Babcock St NE Palm Bay, FL 32905

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, interview and record review, the facility failed to provide assistance with activities of daily living (ADLs) related to nail care for 1 of 2 dependent residents reviewed for ADLs out of a total sample of 57 residents (#43). Residents Affected - Few Findings: Resident #43 medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including brain bleed, speech/language disorder from stroke, seizures, and paralysis to the right/dominant side of his body. The Minimum Date Set (MDS) Quarterly Assessment, dated 6/29/22, revealed he had severely impaired cognition and indicated he did not reject evaluation or care necessary to achieve the resident's goals for health and well-being. The assessment indicated resident #43 required extensive assistance from one staff for bed mobility, transfers, dressing and for personal hygiene. The document showed resident #43 had functional impairment in both his upper and lower extremities on one side of his body that interfered with daily function or placed him at risk for injury. Resident #43 had a care plan for ADL self-care performance deficit related to previous stroke and paralysis to the right side of his body. Interventions included total assistance with bathing and extensive assistance with personal hygiene. An additional intervention dated 3/30/20 was for staff to check nail length and trim and clean on bath day and as necessary. The intervention specified for staff to report any changes to the nurse. Resident #43 had an additional care plan for potential impairment to skin integrity dated 3/30/20. The goal was for skin breakdown to be minimized through management of nursing interventions. Interventions included staff to prevent resident #43 from scratching and keeping his fingernails short. Review of the July 2022 and August 2022 Medication Administration Records revealed resident #43 did not have any documented behaviors as monitored by nurses every shift as ordered through the two-month period prior to the survey. Review of the Certified Nursing Assistant (CNA) Visual/Bedside [NAME] Report, dated 9/01/22, revealed direction for CNAs under Resident Care to keep fingernails short. Under the Bathing area, it directed CNAs to check nail length, trim and clean on bath day and as necessary. It directed the CNA to report any changes to the nurse. Review of the CNAs Task Flowsheet showed bathing documented as given by CNAs on 8/16/22, 8/18/22, 8/23/22, 8/24/22, 8/25/22, 8/29/22, and 8/30/22. On 8/29/22 at approximately 10:40 AM, resident #43 was observed in the hallway in his wheelchair. The nails on his left hand were clean and trim, but the nails on his right, paralyzed side were very long, yellowed and thickened. He was alert and when asked about his long nails he said Yes. On 8/29/22 at 12:45 PM, resident #43 was again observed in the hallway in his wheelchair. The fingernails on his right hand were long and yellow, with the nail on his thumb and last three fingers the longest. 105985 Page 3 of 22 105985 09/02/2022 Aviata at Palm Bay 5405 Babcock St NE Palm Bay, FL 32905

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 8/30/22 at 3:35 PM, resident #43 was again in his wheelchair in the hallway. His nails were still long, the nail on his first finger was shorter than the rest, but jagged and thick. On 8/30/22 at 4:32 PM, resident #43's assigned CNA C verified his nails on his right hand were over a half inch long and very thick. She stated she had wondered who should cut resident #43's long nails on his right hand. She stated she had noticed the length of them previously but confirmed she had never mentioned them to the assigned nurse. She stated she was unable to cut the nails on his right hand herself because of how thick they were. CNA C stated nails should be cleaned daily and cut whenever the resident was given a shower or bath, especially to keep the nails trim so they don't scratch themselves. She was unable to say why she never notified the nurse or anyone else of not being able to cut his nails on the right hand. On 8/30/22 at approximately 4:51 PM, the South Wing Unit Manager (UM) confirmed resident #43's long nails on his right hand. She stated sometimes resident #43 did not always let them cut his nails. She was unable to provide documentation that showed staff had offered to cut his nails and he refused. The resident was asked if he would allow staff to cut his nails and he nodded yes. The UM was also unable to find documentation that showed the condition of resident #43's nails on his right hand as yellow and extremely thickened. She stated the podiatrist had seen resident #43 but he does not cut fingernails, she stated sometimes therapy helps to cut the resident's nails. She stated that although resident #43 did not use that hand, there was a risk of the nails being infected, unclean or could cause a skin tear inadvertently. She confirmed that the physician had not been notified of resident #43's nails on his right hand as far as she knew. Review of resident #43's medical record did not reveal any documentation of refusals by resident #43 for nail care and documentation of the condition of his nails by staff. There was no documentation of notification by staff to the physician of resident #43's refusal of nail care or report of difficulty cutting his nails due to their thickened condition. On 8/30/22 at 5:44 PM, the South Wing UM stated she notified resident #43's doctor and he was coming to see him for his nails. In interviews on 8/31/22 at 12 PM and 9/02/22 at 6 PM, the Medical Director stated resident #43's nails needed to be treated for a fungal infection and he indicated they might fall off. He stated the nails were unable to be cut with regular clippers and they would need to order a special tool to trim them. He stated his expectation was nurses should notify the physician if the resident was not receiving recommended or planned care due to the resident's refusal or other reasons. On 9/01/22 at 2:40 PM, the Director of Nursing (DON) stated the expectation was for CNAs to clean and cut resident's nails when they were bathed. She explained part of the care included cleaning and trimming the nails. She stated she expected CNAs to notify they nurse if a resident refuses care or if there was some reason they were unable to cut or clean them. She explained the nurse was expected to determine why the resident refused care or the CNA was unable to provide the care and notify the physician so further guidance could be provided. Review of the Job Description Nurse Tech I, dated 11/01/06, revealed the primary purpose of the position as a CNA was to provide assigned residents with routine daily nursing care and services in accordance with the resident's assessment and care plan. 105985 Page 4 of 22 105985 09/02/2022 Aviata at Palm Bay 5405 Babcock St NE Palm Bay, FL 32905

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow the physician's order for wound treatment for 1 of 2 sampled residents reviewed for skin condition out of a total sample of 57 residents (#50). Residents Affected - Few Findings: Resident #50's medical record revealed the resident was initially admitted on [DATE], then readmitted on [DATE]. Her diagnoses included atrial fibrillation, history of falling, primary open-angle glaucoma, macular degeneration and unsteadiness on feet. Her most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 06/26/22 revealed she had a Brief Interview for Mental Status (BIMS) score of 13, indicating her cognition was intact. She required supervision for bed mobility and transfers, supervision with one staff physical assistance for toilet use and personal hygiene and used a manual wheelchair for mobility. Review of physician's orders, dated 08/24/22, read, Clean wound with normal saline, pat dry, then apply steri-strips, leave it open to air. It did not specify the location of the wound. There was also no documentation about the frequency of the order. Her care plan, initiated on 08/24/22, read, The resident has a skin tear: leg . Interventions were to monitor/document location, size and treatment of skin tear, report abnormalities . treatment per orders . On 08/29/22 at 12:57 PM, resident #50 was observed sitting on her wheelchair dressed in day clothes. She had a covered dressing on her left upper shin, dated 08/27/22, that had initials CM. On 08/30/22 at 12:37 PM, resident #50 sat at the side of her bed with the same dressing still noted on her left upper shin. On 08/31/22 at 11:24 AM, the dressing was observed with wrinkled edges and remained unchanged. On 08/31/22 at 11:31 AM, Licensed Practical Nurse (LPN) A stated the only treatment for resident #50 was to apply a pillow under her calf while in bed as tolerated. She confirmed there was no other treatment ordered for her. On 08/31/22 at 11:40 AM, the North Wing Unit Manager stated resident #50 had a treatment order for her leg but the directions were not clearly written. She also stated the order was supposed to be a onetime order, the wound was supposed to be left open to air, and not covered. She acknowledged the nurses did not follow the physician order. The facility's policy and procedures for Dressing Change, revised on 12/06/2017, read, Policy: A clean dressing will be applied by a nurse to a wound as ordered to promote healing. Sterile dressing will only be used only if specifically ordered. 105985 Page 5 of 22 105985 09/02/2022 Aviata at Palm Bay 5405 Babcock St NE Palm Bay, FL 32905

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 14. Resident #59's medical record revealed the resident was admitted on [DATE]. Her diagnoses included encephalopathy, muscle weakness, other lack of coordination, unsteadiness on feet, difficulty in walking, psychosis, delusional disorders and unspecified mood disorder. Her admission MDS assessment dated [DATE] revealed she had severe cognitive impairment. She required limited assistance of one staff for bed mobility, dressing, eating and personal hygiene; she also required supervision for transfer. Resident #59 used a walker or wheelchair for mobility. Record review revealed that on 08/29/22, resident #59 had orders to discontinue PT services after 08/29/22 treatment. The Therapy Communication to Restorative Nursing Program form dated 08/29/22 indicated resident #59 had weakness on bilateral lower extremities and decrease in standing balance. The recommendations read, walk the patient outside her room/in the hallway for 100 feet using a cane . The form was signed by Physical Therapist Q and by an RNP CNA with unrecognizable initials. On 09/02/22 at 2:34 PM, Physical Therapist Q stated the recommendation for the RNP would encourage resident #59 to walk outside her room. She also stated she was not aware if the resident was included in the RNP. 15. Resident #19's medical record revealed she was admitted on [DATE]. Her diagnoses included encephalopathy, muscle weakness, difficulty in walking, unsteadiness on feet, dementia and bipolar disorder. Her admission MDS assessment dated [DATE] indicated resident #19 was severely impaired. She required limited assistance of one staff for bed mobility, transfer and toilet use while extensive assistance of one staff for dressing and personal hygiene. She used a wheelchair for mobility. Record review revealed that on 08/14/22, an order was made to discontinue Skilled OT services to RNP. On 08/11/22, resident #19 was referred to the RNP because she needed structured upper body exercise program. She was recommended to perform 15 independent arm exercises to increase upper body strength. The referral was signed by Certified Occupational Therapist Assistant (COTA) R then initialed by an RNP CNA. On 09/02/22 at 2:46 PM, Physical Therapist Q stated resident #19 was recommended by OT to follow a Home Exercise Program (HEP) for arm exercises. Physical Therapist Q also recommended for her to continue to ambulate 400 feet. Physical Therapist Q stated if the resident would not be under RNP this could lead to decrease of her arm strength, muscle weakness and decrease endurance. 16. Resident #11's medical record revealed the resident was admitted on [DATE]. Her diagnoses included dementia, anxiety disorder and muscle weakness. Her significant change in status MDS assessment dated [DATE] indicated she was severely impaired. 105985 Page 6 of 22 105985 09/02/2022 Aviata at Palm Bay 5405 Babcock St NE Palm Bay, FL 32905

F 0688 Level of Harm - Minimal harm or potential for actual harm She required extensive assistance of one staff for bed mobility, transfer and eating. She was totally dependent on one staff for toilet use and personal hygiene. She used a wheelchair for mobility. Record review revealed that on 07/11/22, an order read D/C PT services after today's PT session. On 07/22/20, an order was made that resident #11 may have restorative/maintenance program as indicated. Residents Affected - Some Her care plan, initiated on 01/11/19 and revised on 08/08/19, indicated resident #11 had ADL self-care performance deficits related to dementia. Intervention initiated on 09/03/21 read, Nursing rehab/restorative: ambulation as recommended by therapy and as tolerated by resident. The Therapy Communication to Restorative Nursing Program form dated 07/11/22 revealed resident #11 required moderate assistance with sit to stand and minimal to moderate assistance with pivot transfer due to bilateral lower extremity weakness and decrease in balance. She was recommended to receive PROM exercises on her legs for hip flexion, hip abduction/adduction, knee flexion/extension and ankle dorsiflexion/plantar flexion for 10 repetitions with 2-3 sets as tolerated. The form was signed by Physical Therapist Q and initialed by an RNP CNA. On 09/02/22 at 3:05 PM, Physical Therapist Q stated if resident #11 would not be included in the RNP, there could be a faster decline of function in walking. 7. Resident #7's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included repeated falls, restless syndrome, and type 2 diabetes with diabetic neuropathy. The MDS quarterly assessment with Assessment Reference Date (ARD) of 5/21/22 revealed resident #7 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated she was cognitively intact. The MDS showed resident #7 required extensive assistance on staff for bed mobility, transfer, locomotion on and off the unit, dressing, toilet use, and personal hygiene. The assessment noted no rejection of care necessary to obtain goals for her health and well-being. The Therapy Communication to Restorative Nursing Program form dated 6/16/22 revealed resident #7 needed to continue with ambulation program in order to maintain current level of mobility. The recommendation was for 2-3 times per week. Review of the physician's orders, progress notes and comprehensive care plan for resident #7 revealed no addition of the RNP. On 9/02/22 at 1:43 PM, resident #7 stated she did good while she received PT a couple of months ago. Resident #7 explained she was supposed to get someone to walk her 3 times per week after she finished PT, but the RNP CNA could only see her when he had time. She indicated she learned the RNP CNA was working on multiple things, so he saw her when he had time. She stated the RNP CNA continued coming when he could until she was told she needed to return to PT. She indicated she restarted PT services this week and was told by the Physical Therapist she was not doing so good. Resident #7 indicated she could not walk as fast she did before and felt this was because of not getting the RNP exercises for so long. On 9/02/22 at 5:26 PM, Physical Therapist R indicated resident #7 was on PT case load as of 8/25/22. She stated resident #7 was discharged from PT on 6/16/22. She noted when resident #7 was discharged , she walked with stand-by assistance (SBA), using 2-wheeled walker (2WW) for 200-300 feet. She 105985 Page 7 of 22 105985 09/02/2022 Aviata at Palm Bay 5405 Babcock St NE Palm Bay, FL 32905

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated the recommendation to RNP was to continue walking between 200-300 feet or whatever the resident tolerated. She explained the PT evaluation from 8/25/22 showed resident #7 was walking with contact guard assist using a 2WW for 100 feet. She explained this showed a decrease on resident #7's ability to walk. 8. Resident #21's medical record revealed he was admitted to the facility on [DATE] and readmitted from an acute care hospital on 5/18/22. His diagnoses included stroke with left side weakness, aphasia, and history of falls. The MDS quarterly assessment with ARD of 5/31/22 revealed resident #21 had a BIMS score of 0 which indicated he was severely cognitively impaired. The MDS showed resident #21 required extensive assistance on staff for bed mobility, transfer, locomotion on and off the unit, dressing, and personal hygiene. The assessment noted no rejection of care necessary to obtain goals for his health and well-being. The Therapy Communication to Restorative Nursing Program form dated 7/11/22 revealed resident #21 had contractures on his hips and knees, and decreased lower extremity strength, sitting balance and cognition. The recommendation was for the RNP CNA to perform ROM to both knees. Review of the physician's order dated 7/15/22 read, Restorative Care. The comprehensive care plan for resident #21 did not include the RNP. A care plan for risk of falls initiated on 3/04/22 included a goal to minimize the risk of falls. The interventions included to encourage the resident to participate in activities that promoted exercise, physical activity for strengthening and improved mobility. Review of Change in Condition form revealed resident #21 had sustained falls on 6/26/22 and 8/23/22. On 9/02/22 at 5:20 PM, Physical Therapist R stated resident #21 was currently on case load. She explained he had recommendation for RNP on 7/11/22 for ROM on knees to prevent further tightness. She indicated a negative outcome of not getting RNP could be for the resident to get more contractures. 9. Review of resident #23's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included compression fracture of thoracic vertebra, multiple myeloma and low back pain. Review of the MDS 5-Day Assessment with ARD of 6/08/22 revealed resident #23 had a BIMS score of 11 which indicated she was moderately cognitively impaired. The MDS showed resident #23 required extensive assistance on staff for transfer, and limited assistance for bed mobility, locomotion on and off the unit, and eating. Resident #21 was totally dependent on staff for dressing, toileting and personal hygiene. The assessment noted no rejection of care necessary to obtain goals for her health and well-being. Review of the Therapy Communication to Restorative Nursing Program form dated 8/13/22 revealed resident #23 had balance and gait deficits and decreased strength. The recommendation was for the RNP CNA to perform active ROM to bilateral lower extremities with 20 repetitions. Review of the comprehensive care plan for resident #23 did not include the RNP. 105985 Page 8 of 22 105985 09/02/2022 Aviata at Palm Bay 5405 Babcock St NE Palm Bay, FL 32905

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 9/02/22 at 1:38 PM, resident #23 stated when she finished working with therapy, she should had received RNP. She stated she had not been able to walk after therapy because she developed clots in her legs. On 9/02/22 at 5:23 PM, Physical Therapist R stated therapy recommended the RNP CNA to provide active ROM exercises to the lower extremities with 20 repetitions. She explained a possible negative outcome for resident #23 included tightness, functional decline, atrophy or muscle weakness. 10. Resident #85's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included dementia, depression, type 2 diabetes and atrial fibrillation. Review of the MDS quarterly assessment with ARD of 8/2/22 revealed resident #85 had a BIMS score of 3 which indicated he was severely cognitively impaired. The MDS showed resident #85 was totally dependent on staff for all the ADLs. The assessment noted no rejection of care necessary to obtain goals for his health and well-being. The Quarterly MDS with ARD of 5/2/22 revealed resident #85 required extensive assistance from one staff for bed mobility. The Quarterly MDS with ARD of 8/2/22 showed resident #85 required 2-staff for bed mobility and transfer. Review of the Therapy Communication to Restorative Nursing Program form dated 7/4/21 revealed resident #85 had bilateral legs weakness. The recommendation from therapy to the RNP CNA read, Passive ROM on both legs x 10 reps x 1-2 sets as tolerated for hip flexion, hip abduction/adduction, knee flexion/extension, ankle dorsiflexion/plant flexion. Passive ROM on both arms x 10 reps x 1-2 sets as tolerated for straightening/bending of elbows, raising the arm from the shoulder, touching the shoulder with the opposite hand, bend the wrist up and down. Review of the comprehensive care plan for resident #85 did not include interventions for the RNP. On 9/01/22 at 3:47 PM, the Director of Nursing (DON) explained the Assistant Director of Nursing (ADON) was responsible for the RNP, but no one filled that position consistently. The DON explained they did not have a nurse in the facility to assign the RNP to and they were working on hiring an ADON. The DON said she did not have the manpower to hire someone as the ADON. The DON stated they brainstormed ideas and considered the possibility of assigning the RNP to the Unit Manager (UM) or the MDS Coordinator, but they concluded both already had a lot on their plates. The DON stated the facility had only one MDS Coordinator and for a time, only one UM for both units. The DON explained they had discussions during meetings on who could possibly manage the RNP, but no solution came up. The DON acknowledged she did not oversee the RNP to run as it was intended. The DON stated the Director of Rehabilitation knew about the lack of oversight of the RNP and was upset about it. The DON explained there were 2 CNAs assigned to the RNP, but one was assigned to care for residents at times and often had to accompany residents to their scheduled outside appointments. The DON indicated she was not able to set up the RNP. The DON explained the process should had included for her to enter a physician's order, tasks for the RNP CNA to document the exercises and update of the care plan. The DON stated the root cause of not providing the RNP was lack of staff for the positions. On 9/01/22 at 6:17 PM, the Divisional Director of Clinical Services (DDCS) stated the facility knew the RNP process was broken. She explained the communication from the Therapy Department should had been given to a nurse and the nurse make the determination if a resident needed the RNP and timeframe. The DDCS did not know which residents were supposed to be on the RNP. She said, We don't have the 105985 Page 9 of 22 105985 09/02/2022 Aviata at Palm Bay 5405 Babcock St NE Palm Bay, FL 32905

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some program. She indicated they were not able to locate any documentation to say what the RNP CNA had done and not done. On 9/01/22 at 6:25 PM, the Director of Rehabilitation confirmed she was working with the RNP CNA directly. She indicated she had been giving the recommendation form to the RNP CNA for at least a year and a half and has only given it to the RNP CNA. She indicated there used to be 2 RNP CNAs but now was just the one. She explained they trained the RNP CNA for new residents, but the CNA was familiar with the long-term residents and were familiar with most of the exercises they needed. She stated she had seen some residents return to therapy after they were referred to the RNP. The Director of Rehabilitation explained they used to discuss the residents during a RNP meeting they used to have every 2 weeks and would receive report on how the residents were progressing. She indicated during that meeting, they would learn if a resident was refusing or needed more therapy and they would get those residents back in therapy, but this stopped a couple of years ago. She stated there had been discussions about the broken RNP process with the DON, who would say she knew about it, and was going to get an ADON. The Director of Rehabilitation stated they continued referring to the RNP because they wanted to maintain those residents' functional abilities. She explained she would talk to RNP CNA P and he would tell her he had a different assignment that day. She remembered a resident who asked her if he was supposed to be in the RNP because he had not been receiving it. She stated when she asked RNP CNA P, he would either see the resident to provide RNP, mention he was working in a unit, or taking a resident to a doctor's appointment. She stated she felt it was important for the resident to continue the RNP to maintain or progress on their abilities. She stated she did not know if this was ever addressed in the Quality Assurance and Performance Improvement (QAPI) meetings as she did not participate in them. She mentioned her company did not have them going to the QAPI meetings. The Director of Rehabilitation stated she participated in the facility's morning meeting and recalled they had brainstormed ideas on how to get the RNP working again. She stated at one point she was going to try to take it on herself, but it was too much. She indicated the Medical Director was not involved in the Therapy Program. On 9/02/22 at 2:24 PM, CNA E stated she did not perform the RNP. She indicated they had CNAs assigned for the RNP. CNA E explained she did not do exercises with her residents and did not apply splints. On 9/02/22 at 2:29 PM, CNA G stated she had never done the RNP, as she was not trained for it. On 9/02/22 at 2:30 PM, CNA F stated she had not received training on the RNP. CNA F explained CNAs P and Q were responsible for obtaining residents' weights among other things but were often assigned to care for residents when they did not have enough staff. She stated CNAs P and Q fed residents who required assistance. On 9/02/22 at 2:35 PM, CNA H stated she did not do or receive training for the RNP. On 9/02/22 at 2:40 PM, CNA I indicated she worked the 3 to 11 PM shift and was not familiar with the RNP. On 9/02/22 at 2:45 PM, CNA J stated she was not sure what the RNP was. She indicated she did not receive training about RNP. On 9/02/22 at 2:48 PM, CNA K stated she did not do the RNP. She stated she had not seen the RNP CNAs working with residents in her area in a while. 105985 Page 10 of 22 105985 09/02/2022 Aviata at Palm Bay 5405 Babcock St NE Palm Bay, FL 32905

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 9/02/22 at 4:41 PM, the MDS Coordinator stated the facility did not have a RNP. She explained therapy wrote the communication note and handed it to the RNP CNAs. The MDS Coordinator stated the facility did not have a RNP in over a year. She noted when the RNP was in place, they had a RNP nurse who received the forms from therapy, entered an order in the medical record, and the RNP CNAs documented the exercises performed and the time spent with the resident. She added the RNP Nurse also entered a progress note weekly. The MDS Coordinator said they have not claimed RNP in the assessments . nothing was written . so they cannot claim anything in the MDS. The MDS Coordinator indicated the Director of Rehabilitation gave a copy of the Therapy Communication to Restorative Nursing Program form to RNP CNA P and she would be informed the resident was discharged from therapy services and transitioned to the RNP. She said, It is very important to have an accurate MDS. On 9/02/22 at 5:21 PM, Physical Therapist R stated therapy recommended the RNP CNA provide resident #85 with PROM on both legs and arms. She explained if this was not done, resident #85 had an increased risk for contractures on legs and arms. She noted therapy provided education to the resident and his wife so she could also do exercises with him as she was in the facility almost every day. On 9/02/22 at 5:59 PM, the Medical Director stated he was aware of the facility's manpower issue and unable to provide the RNP. He explained the facility did not have a person to run the RNP as they did not have an ADON. He indicated the purpose of the RNP was to maintain resident's function or prevent a decline and contractures. He explained residents could potentially experience falls because of those reasons. He said it was, Absolutely important for nursing to follow the therapy recommendations, if possible. He confirmed he signed the discharge summary from therapy which included their recommendations. He noted he would expect nursing to inform him of any refusals of care from residents. He indicated he was not notified of residents not seen by RNP CNAs and was not aware of the current situation with RNP CNA assignments. On 9/02/22 at 4:41 PM, the MDS Coordinator stated the facility did not have a RNP. She explained therapy wrote the communication note and handed it to the RNP CNAs. The MDS Coordinator stated the facility did not have a RNP in over a year. She noted when the RNP was in place, they had a RNP nurse who received the forms from therapy, entered an order in the medical record, and the RNP CNAs documented the exercises performed and the time spent with the resident. She added the RNP Nurse also entered a progress note weekly. The MDS Coordinator said they have not claimed RNP in the assessments . nothing was written . so they cannot claim anything in the MDS. The MDS Coordinator indicated the Director of Rehabilitation gave a copy of the Therapy Communication to Restorative Nursing Program form to RNP CNA P and she would be informed the resident was discharged from therapy services and transitioned to the RNP. She said, It is very important to have an accurate MDS. On 9/02/22 at 5:21 PM, Physical Therapist R stated therapy recommended the RNP CNA provide resident #85 with PROM on both legs and arms. She explained if this was not done, resident #85 had an increased risk for contractures on legs and arms. She noted therapy provided education to the resident and his wife so she could also do exercises with him as she was in the facility almost every day. On 9/02/22 at 5:59 PM, the Medical Director stated he was aware of the facility's manpower issue and unable to provide the RNP. He explained the facility did not have a person to run the RNP as they did not have an ADON. He indicated the purpose of the RNP was to maintain resident's function or prevent a decline and contractures. He explained residents could potentially experience falls as a result of those reasons. He said it was, Absolutely important for nursing to follow the therapy recommendations, if possible. He confirmed he signed the discharge summary from therapy which included their recommendations. He noted he would expect nursing to inform him of any refusals of care from 105985 Page 11 of 22 105985 09/02/2022 Aviata at Palm Bay 5405 Babcock St NE Palm Bay, FL 32905

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some residents. He indicated he was not notified of residents not seen by RNP CNAs and was not aware of the current situation with RNP CNA assignments. Based on observation, interview and record review, the facility failed to ensure residents referred to the restorative nursing program (RNP) received the recommended treatments and exercises to maintain or improve mobility and function for 19 of 19 residents reviewed for RNP, out of a total sample of 57 residents (#43, 93, 34, 18, 62, 83, 7, 21, 23, 85, 25, 69, 52, 59, 19, 11, 17, 78 & 97). Findings: 1. Resident #43 was admitted to the facility on [DATE] with diagnoses that included brain bleed (stroke), seizures, and paralysis to the right/dominant side of his body. The Minimum Date Set (MDS) Quarterly Assessment, dated 6/29/22, revealed he had severely impaired cognition and indicated he had no physical, verbal, or other behaviors towards others and did not reject evaluation or care necessary to achieve the resident's goals for health and well-being. The assessment indicated resident #43 required extensive assistance from one staff for bed mobility, transfers, dressing and for personal hygiene. The document showed resident #42 had functional impairment in both his upper and lower extremities on one side of his body that interfered with daily function or placed him at risk for injury. The assessment indicated resident #43 received no days of RNP. Resident #43 had a care plan for activities of daily living (ADLs) self-care performance deficit related to previous stroke and paralysis to the right side of his body. Interventions included monitor, document and report any changes, potential for improvement or declines in function, Physical Therapy/Occupational Therapy (PT/OT) evaluation and treatment as ordered and directed staff to refer to therapy care plans. Resident #43's medical record did not contain a care plan addressing his risk for contracture of his paralyzed side or for wearing of a splint or exercises to prevent contractures. Review of the Order Summary Report for active orders, dated 8/31/22, revealed resident #43 had an order to discontinue (DC) skilled OT with direction for the resident to continue to wear the right-hand splint for six hours as tolerated dated 1/27/22. Resident #43 had an order to continue skilled OT for three times a week for four weeks starting on 7/04/22. An additional order to DC OT services and continue to wear a right hand splint for six hours as tolerated was dated on 9/15/21. A current DC order for the most recent OT was not found. Review of the Therapy Communication to Restorative Nursing Program PT referral dated 6/17/22 revealed resident #43 had a recommendation for exercise on the recumbent cross trainer machine at level 7 for a duration of 15 minutes to maintain his current level of function and prevent functional decline. Review of the Therapy Communication to Restorative Nursing Program OT referral dated 7/17/22 revealed recommendations for RNP to put on and take off the splint to the right upper extremity for 6 hours daily and for passive range of motion (PROM) exercises to the right upper extremity in all planes to decrease contractures. On 8/29/22 at approximately 10:40 AM, resident #43 was observed in the hallway in his wheelchair. He was alert but had unintelligible speech. He was not wearing a splint on his right arm. On 8/29/22 at 12:45 PM, resident #43 was observed in the hallway in his wheelchair. He did not have 105985 Page 12 of 22 105985 09/02/2022 Aviata at Palm Bay 5405 Babcock St NE Palm Bay, FL 32905

F 0688 Level of Harm - Minimal harm or potential for actual harm a splint on his right hand, and he indicated that his right side was paralyzed by picking up the right arm with the left hand and moving it around. On 8/30/22 at 10:15 AM, resident #43 was observed in his wheelchair near the door to the lobby. He was dressed and alert and did not have a splint on his right hand. Residents Affected - Some On 8/30/22 at 3:35 PM, resident #43 was observed in his wheelchair in the hallway. He was not wearing a splint on his right hand. On 8/30/22 at 4:32 PM, Certified Nursing Assistant (CNA) C was unsure if resident #43 was supposed to wear a splint on his right arm. She stated she recalled seeing one a while back, but she had not seen it recently and was not sure where it was. With resident #43's permission, CNA C searched resident #43's drawers and found the splint in a bottom drawer next to his bed. She stated it was the splint he used to wear. CNA C was unsure who was supposed to apply resident #43's splint, and said it wasn't the CNA's job to do it, maybe therapy or the nurses. On 8/30/22 at 4:46 PM, assigned Licensed Practical Nurse (LPN) B stated she did not know anything about resident #43's splint. She stated she did not hear anything about it in report and she had not seen it. She was not sure who was supposed to apply the splint. On 8/30/22 at approximately 4:51 PM, the South Wing Unit Manager (UM) stated the restorative aide was supposed to apply resident #43's splint. She verified the order in the computer to DC occupational therapy and for resident #43 to continue to wear the right-hand splint as tolerated for 6 hours. She was unable to find any documentation in resident #43's record concerning application of his right-hand splint other than the order. She explained when therapy discharged the residents, they wrote a referral to the RNP and gave them the paperwork describing the exercises or applications they need performed. The South Wing UM was unable to find a care plan for resident #43's splint and for prevention of reduced range of motion (ROM) to his right paralyzed side. She stated resident #43 was supposed to wear the splint to prevent his hand from contracting over time and to keep it more stable. In interviews on 8/30/22 at 5:22 PM, 5:44 PM and on 9/02/22 at 4:41 PM, the MDS coordinator confirmed there was no care plan addressing resident #43's need for a splint but stated there should be. She stated the restorative nurse role was part of the Assistant Director of Nursing's (ADON) responsibilities but since there was no ADON it fell to the Director of Nursing (DON). The MDS coordinator indicated she had not been able to claim RNP hours on the residents' MDS assessments for a very long time because there was no documentation of RNP being done for anyone. On 9/01/22 at 9:43 AM, Restorative CNA P stated he and part time Restorative CNA Q received the referrals from therapy for the RNP program but there was no one running the program since the ADON left several years ago. Restorative CNA P was not able to say when or if he had last placed resident #43's splint on his arm as per his referral. He was not able to find resident #43's referral in the large pile of loose referral sheets he kept in the cabinet. He was able to produce a handwritten list which he stated was his cheat sheet that listed the residents who required splints. Resident #43 was listed on the paper, but it did not give direction as to how often or how long the residents on the list were supposed to wear the splints. Restorative CNA P stated there was no schedule for which residents needed RNP or when to see them. He stated some days he was not able to get any of the RNP work done because the referrals had piled up since there was no one running the program to evaluate and discharge the residents when they no longer needed the program. He related therapy kept bringing more and more referrals and said, Restorative is just not getting done. Restorative CNA P revealed he 105985 Page 13 of 22 105985 09/02/2022 Aviata at Palm Bay 5405 Babcock St NE Palm Bay, FL 32905

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some hadn't documented RNP on the residents because no one had set up the program for him to document since the ADON left several years ago. He stated he often did, everything but restorative, when he was at work because he was often asked to work an assignment when staffing was short or was asked to take residents to appointments as there was no transportation person. He stated in addition, he had to weigh all of the residents in the facility which usually took him 3 or 4 days to finish by himself. Restorative CNA P related he and Restorative CNA Q were pulled in so many different ways. He explained other CNAs could help with the RNP program to do the exercises or the splints if only they were trained to do it. He explained a few of the CNAs who had been around might know how but they expected him to do it. He stated due to his limited time he would prioritize who he would see for restorative services. The Restorative CNA explained he would decide to see the residents he felt really wanted it and would decide to not see residents like those in the dementia unit who were walking around all day. Review of the CNA Task Flowsheet did not reveal RNP documentation by CNAs during the 30-day look back period starting on 9/01/22. In interviews on 9/01/22 at 12:50 PM and 3:46 PM, the DON stated that since she had been at the facility over the past 18 months there had not been an ADON to run the RNP, so it fell on her to do it. She stated she attempted at first to run it but didn't have the manpower. She stated the two Restorative CNAs were left to run the program themselves and continued to get referrals from therapy. She explained the Restorative CNAs were not being supervised and said, it's not successful and we have to staff to the needs of the residents. She confirmed Restorative CNAs P and Q were both often pulled to cover floor assignments or to take residents to appointments. She acknowledged that one full time Restorative CNA was not enough to complete all the work for RNP, especially when they were asked to cover other functions in the facility. The DON could not answer if residents had to go back on therapy case load due to not having the RNP services available. In interviews on 9/01/22 at 5:52 PM and 6:16 PM, the Regional Nurse stated the RNP process was broken and explained therapists were giving the referrals to the CNAs to manage the program when it should be the Restorative nurse. She said, No one had been in place to do it and when they had filled the position, they did not stay long enough to manage the program. She stated they were unable to say which residents were supposed to be on RNP and were unable to locate any documentation from the Restorative CNAs that indicated residents had been seen. Review of the document OT Recertification for the dates 7/04/22-8/02/22 revealed resident #43 had a goal to tolerate wearing his right-hand splint for six hours to prevent further contracture. At baseline, the document indicated on 6/06/22 the resident tolerated the splint for five hours, and on 7/04/22 he tolerated the splint for five-to-six-hour intervals with no signs of redness or skin breakdown. In interviews on 8/30/22 at 5:24 PM, 9/01/22 at 12:36 PM and 6:26 PM, the Therapy Director stated the Restorative CNA was supposed to apply resident #43's splint and was to noti[TRUNCATED] 105985 Page 14 of 22 105985 09/02/2022 Aviata at Palm Bay 5405 Babcock St NE Palm Bay, FL 32905

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident received supplemental oxygen as ordered for 1 of 1 resident reviewed for respiratory care out of 57 total sampled residents (#29). Residents Affected - Few Findings: Resident #29's medical record revealed she was admitted to the facility on [DATE] and readmitted from an acute care hospital on 5/19/22. Her diagnoses included obstructive sleep apnea (OSA), cardiomyopathy, and type 2 diabetes. The Minimum Data Set (MDS) quarterly assessment with Assessment Reference Date of 6/15/22 revealed resident #29 had a Brief Interview for Mental Status score of 15 which indicated she was cognitively intact. The MDS revealed resident #29 used oxygen therapy in the previous 14 days. The quarterly assessment noted no rejection of care necessary to obtain goals for her health and well-being. The medical record revealed a physician's order dated 7/14/22 for Continuous Positive Airway Pressure (CPAP) at night and as needed (PRN) as tolerated with 2 liters per minute (l/min) of oxygen at night related to OSA. A second order read, Oxygen 2 l/min with CPAP at night and PRN. The nurse's progress note on 7/09/22 revealed oxygen and CPAP were not in use. Nurse's progress note on 7/28/22 and 8/02/22 revealed oxygen was not in use but the CPAP was used. Resident #29's care plan, dated 6/27/22 for risk of complications related to OSA, revealed a goal for the resident to have no signs/symptoms of poor oxygen absorption. The interventions included to change the tubing/mask as ordered, give medications as ordered, and oxygen via nasal canula at 2 liters at night. On 8/29/22 at 11:42 AM, resident #29 stated she had not used the CPAP because the mask was too big, and someone had ordered a new one about 2 weeks ago, but she had not received it. She explained she had been weeks without using the CPAP and she felt tired when CPAP was not used. Resident #29 indicated she did not use oxygen. There was no oxygen concentrator or supplies observed in her room. On 8/30/22 at 10:29 AM, resident #29 indicated she did not have a good night because the CPAP was still not used. She explained the CPAP was to be used at night. The CPAP machine was observed on the nightstand with a face mask covered in a plastic bag. On 8/31/22 at 11:54 AM, Certified Nursing Assistant (CNA) L explained he worked from 7 AM to 3 PM, received report from the night shift CNA, and he checked his residents when he first came in the morning. CNA L stated resident #29 was in bed and he had not seen her using a CPAP machine. He was not aware of any issues with the CPAP. On 8/31/22 at 3:11 PM, Licensed Practical Nurse (LPN) M stated resident #29 was alert and oriented, and she did not see the CPAP on the resident when she came in at 7 AM. She was not aware of any issues with the CPAP for resident #29. Resident #29's Treatment Administration Record revealed nurses documented CPAP with oxygen given at night 29 out of 31 days in August 2022. 105985 Page 15 of 22 105985 09/02/2022 Aviata at Palm Bay 5405 Babcock St NE Palm Bay, FL 32905

F 0695 Level of Harm - Minimal harm or potential for actual harm On 9/01/22 at 1:35 PM, the North Wing Unit Manager (UM) explained resident #29 needed a new mask which the Respiratory Therapist (RT) ordered and was on its way to the facility. At 2:43 PM, the UM went into resident #29's room and confirmed there was no oxygen tank, concentrator or supplies in the room. The UM stated nurses did not follow the physician's order for oxygen use. Resident #29 stated she did not have oxygen in her room. The UM indicated the nurses should have ensured oxygen was in place. Residents Affected - Few On 9/01/22 at 4:19 PM, the Director of Nursing (DON) explained resident #29 had been transferred to the hospital a couple of times and once had an order for oxygen at night to keep her oxygen saturation above 95% while waiting for the CPAP. The DON acknowledged the oxygen was not in the resident's room. Review of the facility Oxygen Therapy policy dated 8/28/17 revealed the procedure included to review the physician's order and gather the necessary equipment. 105985 Page 16 of 22 105985 09/02/2022 Aviata at Palm Bay 5405 Babcock St NE Palm Bay, FL 32905

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on observation, interview, and record review the facility failed to ensure adequate nurse staffing to meet the needs of residents who required splinting and range of motion services through the Restorative Nursing Program (RNP) for 19 of 19 residents reviewed who were referred to the RNP of a total sample of 57 residents (#78, 97, 25, 62, 52, 69, 17, 83, 59, 21, 11, 18, 85, 23, 43, 19, 34, 93 & 7). Findings: Cross reference F688 and F835. Review of the Facility Assessment with most recent revision date 3/28/22 indicated Restorative Nursing and Contracture Care as part of the needed service and care provided by the facility to its residents. The document indicated the majority of the facility's residents were geriatric and required assistance from one or two staff for activities of daily living (ADLs). The assessment revealed staffing was a function of census and acuity and assignments would be made with respect to hours required to sufficiently meet the care needs of the residents on all shifts. On 9/02/22 at 11:39 AM, Physical Therapist (PT) R stated she held a Doctorate degree in physical therapy and completed PT assessments including the discharge assessment on residents. She stated residents were referred to the restorative nursing program by therapists when they were discharged from therapy to prevent loss of function or decline in mobility. She explained the RNP was important for residents to prevent them from losing what they had gained in therapy and confirmed most residents who received therapy were referred to the RNP for at least some period. In interviews on 9/01/22 at 9:43 AM and 2:53 PM, Restorative Certified Nursing Assistant (CNA) P stated he had worked at the facility as the Restorative CNA approximately 20 years. He opened an unlocked cabinet in the shower room on the North unit and pulled out a loose, large pile of RNP referrals which dated back to September 2021. He had another pile of referrals in a binder on the shelf which he said were from at least 2019. He explained he did not have a list of residents who received restorative nursing care but motioned to the pile of referrals and a handwritten list of residents that needed splints. Restorative CNA P stated there was no schedule for which residents needed RNP or when to see them. He stated some days he was not able to get any of the RNP work done. Restorative CNA P stated he was the only Restorative CNA who worked full time at the facility and explained restorative CNA Q was only scheduled every other weekend to cover when he was off. He stated therapy gave him referrals to the RNP when the residents were discharged from therapy. The Restorative CNA explained no one ran the program since the previous Assistant Director of Nursing (ADON) had left several years ago so the referrals piled up and no one ever got discharged from RNP. He explained the previous ADON ran the RNP program and would enter the resident's referrals into the CNA tasks in the computer and he would document what he did with the residents there. He stated he was trained to apply the recommended splints or perform the exercises, but he was unable to get it done. The Restorative CNA related that in addition to the tasks required for RNP he was also tasked to weigh the residents in the facility which took at least 3 to 4 days to complete. He continued, he also was often tasked to take residents to appointments or to cover for the assigned CNAs if there was a call out or shortage. He indicated for example, he had just come back from taking a resident to an appointment instead of doing restorative work. The Restorative CNA stated he often did, Everything but restorative. He stated he was unable to document any RNP work that he did complete as there was no designated place 105985 Page 17 of 22 105985 09/02/2022 Aviata at Palm Bay 5405 Babcock St NE Palm Bay, FL 32905

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some for him to document his work since the last ADON left. Restorative CNA P stated therapy just kept bringing more and more referrals and said, Restorative is just not getting done. He stated restorative CNA Q and himself were pulled in, So many different ways. He stated there was a third Restorative CNA who quit because she kept getting pulled to work an assignment and not RNP. Restorative CNA P stated he was told by the last ADON that restorative was not supposed to last forever, but he explained since there was no one running the program there was no one to discharge the residents and they kept piling up. Restorative CNA P stated the other CNAs could help with the RNP program to do the exercises or the splints if only they were trained to do it. He explained a few of the CNAs who had been around might know how but they expected him to do it. He stated due to his limited time he would prioritize who he would see for restorative services. The restorative CNA explained he would decide to see the residents who asked or really needed him and would decide to not see the residents like those in the dementia unit who were walking around all day. On 8/30/22 at 4:32 PM, CNA C stated CNAs did not apply splints to residents who needed them and was unaware of who was responsible to put them on. She recalled that therapy sometimes applied them but was unsure of who applied them when the resident was no longer on therapy. On 9/02/22 at 2:24 PM, CNA E stated there were assigned Restorative CNAs to perform RNP exercises and apply splints to residents and the assigned CNAs did not do that. On 9/02/22 at 2:29 PM, CNA G stated she had no training to perform RNP with the residents. On 9/02/22 at 2:30 PM, CNA F stated Restorative CNAs P and Q were assigned to administer the RNP exercises and application of splints, but said they were often given a floor assignment when there wasn't enough staff. On 9/02/22 at 2:48 PM, CNA K stated she did not do RNP exercises with residents on the locked memory care unit, she stated the Restorative CNAs had not come to do RNP with the residents on the memory care unit for a long time. On 9/02/22 at 4:41 PM, the Minimum Data Set (MDS) Coordinator stated the facility didn't really have a Restorative Nursing Program. She stated the facility used to have a RNP nurse that ran the program, but they hadn't had it up and running for a couple of years. She explained the way the program should work was for the nurse to receive the consults from therapy, enter the orders and the care plan into the computer then communicate with MDS and the rest of the RNP team regarding each resident's plan. She further explained the forms would go in a book and there should be documentation from the Restorative CNA and from the Restorative Nurse. She stated they had not been able to claim hours in the MDS for the RNP. She stated the Director of Nursing (DON) was supposed to fill the role of the Restorative Nurse since the ADON position was unfilled but said it had not been done. She stated staffing was a challenge for them at this time. She explained everyone worked multiple roles, such as covering the medication carts when staffing was low, but she felt everyone knew it was not up and running when it should have been. In interviews on 9/01/22 at 12:50 PM and 3:46 PM, the DON stated since she had been at the facility for the past 18 months there had not been an ADON to run the RNP, so it fell on her to do it. She stated she tried to do it at first but, She didn't have the manpower. She explained she tried in the beginning but said she could not keep up with it by herself. She stated she did not have enough staff to assign the task to another nurse because they had been short a Unit Manager and an MDS/Care Plan Nurse at different times. She explained she didn't feel there was anyone else she could assign to 105985 Page 18 of 22 105985 09/02/2022 Aviata at Palm Bay 5405 Babcock St NE Palm Bay, FL 32905

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the RNP task. She stated the problem was discussed with the Director of Rehabilitation who was aware of the problem, but they did not put any actions in place to resolve the matter. She stated the two Restorative CNAs were left to run the program themselves and continued to get the referrals from therapy. She explained the Restorative CNAs were not being supervised and said, It's not successful . we have to staff to the needs of the residents. She confirmed Restorative CNAs P and Q were both often pulled to cover floor assignments or to take residents to appointments. The DON elaborated the caseload might be less if there was someone in the RNP nurse position to run it. The DON stated the facility did not have a transportation aide, so Restorative CNA P was often asked to do it. She acknowledged that one full time Restorative CNA was not enough Restorative staff to complete all the work for RNP, especially when they were asked to cover other functions in the facility. The DON could not answer if residents had to go back on therapy case load due to not having the RNP services available. On 9/01/22 at 1:16 PM, the Staffing Coordinator stated she worked with the DON to schedule the staff based on the census. She stated sometimes they had to pull a staff member for assignments such as to sit one on one with a resident, and if there was a last-minute call out, she would ask the Restorative CNA to cover the assignment but not usually for the whole shift. On 9/01/22 at 5:52 PM, the Regional Nurse stated the Restorative Nurse's position had not been filled for over a year. She stated the facility had hired several ADONs over the past several years after the previous ADON had left, but she indicated none of them remained in the role long enough to take on the responsibilities of the RNP Nurse. Review of the undated document provided by the facility titled, ADON LIST indicated the last successfully filled ADON position ended December 2018. The document revealed of the nine ADONS who were hired in the role after 2018, three stayed in the position for less than one month, the others worked for approximately six months or less. On 9/01/22 at 6:16 PM, after the facility was unable to provide the requested list of residents referred to the RNP program, the Regional Nurse stated, We all know the process is broken, and explained the therapists were giving the referrals to the CNA when the Restorative Nurse should manage that. She said, No one had been in place to do it. She stated they were unable to say which residents were supposed to be on the RNP and they were unable to locate any documentation from the Restorative CNA that indicated residents had been seen. On 9/01/22 at 6:26 PM and 9/02/22 at approximately 11:50 AM, the Therapy Director stated Restorative CNA P would sometimes complain he was getting pulled from Restorative to do other assignments and could not complete his work. When asked why therapy continued to send referrals to the Restorative CNAs when they knew there was no nurse running the program, she explained she had spoken to the DON concerning the lack of a Restorative Nurse and thought they would hire someone to help do it. In a telephone interview on 9/02/22 at 6 PM, the Medical Director stated he had been with the facility for 5 years and the previous ADON left shortly after he started. He stated there had been talk about the need for a Restorative Nurse at that time. The Medical Director explained after the ADON left, there was no consistent ADON to fill the RNP role and run the program. He recalled it being a manpower issue. The Medical Director stated he was neither aware of only one full time restorative CNA employed for the RNP, nor aware the CNA was often pulled to do other tasks at the facility. He confirmed he was not notified residents had not received the RNP as recommended. The Medical Director could not recall any recent discussion of how to fill the role of the Restorative Nurse or how to 105985 Page 19 of 22 105985 09/02/2022 Aviata at Palm Bay 5405 Babcock St NE Palm Bay, FL 32905

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some manage the program without one. He confirmed without the recommended exercises, residents could be at a higher risk for falls or other accidents. The Medical Director stated it was important for the nursing staff to carry out the recommendations made by therapists to prevent declines in residents' functions and abilities. He stated his expectation was for nursing to notify him if residents were not getting the program as ordered. Review of the undated Job Description Director of Nursing I revealed the primary purpose of the position was responsibility to plan, organize, develop and direct the overall operation of the facility's nursing services to ensure the highest degree of quality care was maintained at all times. The duties and responsibilities included recruitment and hiring of a sufficient number of qualified nursing staff to deliver efficient resident care. Review of the undated Job Description Executive Director I revealed the duties and responsibilities included recruitment, hiring and orientation/training for enough qualified staff to carry out facility programs and services. 105985 Page 20 of 22 105985 09/02/2022 Aviata at Palm Bay 5405 Babcock St NE Palm Bay, FL 32905

F 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to utilize its resources effectively to adequately provide staff for the Restorative Nursing Program (RNP) to ensure residents received needed therapy services. Residents Affected - Some Findings: Cross reference F688 and F725. On 09/01/22 at 09:43 AM, Restorative Certified Nursing Assistant (CNA) P acknowledged the RNP was not done. He also stated there used to be three Restorative CNAs but then she resigned and now they were down to two. Restorative CNA P confirmed he had a stack of referrals in his cabinet as far as a year ago which were not done. He added he continued to receive new referrals but nobody could determine who needed to be removed from the program. He admitted he could not perform all the tasks as expected. He stated he was overwhelmed. On 9/01/22 at 1:16 PM, the Staffing Coordinator (SC) confirmed she staffed according to the facility census. She stated she attempted to staff one or two CNAs over the usual number, but sometimes sataff called off. She explained she tried to replace the open position but may have to pull another employee until she could get it covered. She acknowledged the restorative CNAs were used to work as floor CNAs on occasion. On 9/01/22 at 3:46 PM, the Director of Nursing (DON) stated she was responsible for the Restorative Nursing Program (RNP). She recalled she attempted to run the RNP herself when the Assistant Director of Nursing (ADON) resigned. She explained she was unable to keep up with the program on her own and did not have anyone else to help due to their workloads. The DON verified the Restorative CNAs were assigned to do other duties when there was a call off and would not be able to complete the RNP on those days. She stated the department heads had discussed the RNP staffing problem, but did not come to a solution. The DON reported she was unable to oversee the program effectively and the residents did not receive consistent restorative services. On 9/01/22 at 6 PM, the Divisional Director of Clinical Services confirmed the Restorative Nurse's role had not been filled in over a year. She acknowledged the facility had no documentation to support whether restorative therapy services were being provided. She stated, We know the process is broken. On 9/01/22 at 6:25 PM, the Director of Rehabilitation (DOR) stated the previous ADON was in charge of the RNP and kept the program organized and running well a couple of years ago. She explained the program declined when the ADON resigned. The DOR stated she began working with the Restorative CNA directly about a year and a half ago. She explained there were times when the Restorative CNA would say he had another assignment, and he would not be able to provide restorative services that day. She recalled she discussed her concerns regarding the RNP with the DON and was informed the facility was going to get another ADON to run the program. The DOR stated she was going to try and run the RNP herself, but it was too much. On 9/02/22 at 4:41 PM, the Minimum Data Set (MDS) Coordinator stated the facility did not have an RNP. She explained the Therapy Department would write the program and give the recommendations to the 105985 Page 21 of 22 105985 09/02/2022 Aviata at Palm Bay 5405 Babcock St NE Palm Bay, FL 32905

F 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Restorative CNAs, but the program was not really up and running. She reported there was no RNP Nurse, and the Restorative CNAs were not documenting sessions. The MDS Coordinator stated she could not enter minutes into the MDS if they were not documented. She verbalized everyone knew there were problems with the RNP but the facility had not found a solution. On 9/02/22 at 5:59 PM, the Medical Director stated when he first came to the facility, there was an ADON who managed the RNP. He recalled after she left, no one was really managing the program. He explained there was a manpower issue with the operation of the RNP. He stated he was not aware the Restorative CNA had filled in for assignments other than restorative services or that he was unable to see the residents on restorative. The Medical Director could not recall any discussion with the Administrator or DON regarding how to adequately cover the restorative program. On 9/02/22 at 6:20 PM, the Nursing Home Administrator stated she was first made aware of problems with the RNP in July 2021. She recalled she was told the facility had a program, but it was not running properly. The Administrator explained there was no specific person to oversee the RNP. She stated the Restorative CNAs provided services, but residents may not have gotten as many days of restorative care that they needed if the Restorative CNA was pulled to do other tasks. The Administrator acknowledged she had not audited or monitored the program. On 09/02/22 at 6:30 PM, review of the job description for Executive Director I (Administrator) read, The primary purpose of the Executive Director is to direct day-to-day functions of the facility in accordance with current federal, state and local standards, guidelines, and regulations that govern nursing facilities to ensure that the highest degree of quality care can be provided to residents at all times .Duties and Responsibilities . 5. Recruit, hire and provide orientation/training for a sufficient number of qualified staff to carry out facility programs and services . The Facility Assessment Tool, revised on 03/28/22, read, Part 2: Services and care we offer based on our residents' needs . Mobility and fall/fall with injury prevention . transfers, ambulation, restorative nursing, contracture prevention/care . Therapy . PT/OT, Speech/Language, Respiratory, management of braces, splints and prosthetics . 105985 Page 22 of 22