Health inspection·September 2, 2021

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 interviews, record review and facility policy and procedures, the facility failed to provide assistance with showers for one (Resident #12) of five sampled residents reviewed for activities of daily living (ADLs), out of a total sample of 33 residents. Residents Affected - Few The findings include: An interview was conducted with Resident #12 in room [ROOM NUMBER]A on 8/30/21 at 2:26 PM. He stated the only concern he had with the facility was with showers. He had only received a shower seven times since he moved into the facility. He was supposed to get one twice weekly, but the last time he got a shower was around August 3rd. Review of the shower schedule for the north hallway revealed Resident #12 was scheduled for showers on Tuesday and Friday during 3-11 PM shift. (Photographic evidence obtained) A record review for Resident #12 revealed an admission date of 12/11/20, with diagnoses of hemiplegia and hemiparesis following other cerebrovascular disease affecting left dominant side, major depressive disorder, other lack of coordination, muscle weakness, chronic obstructive pulmonary disease (COPD), adjustment disorder with depressed mood. A review of the quarterly minimum data set (MDS) assessment, dated 8/25/21, revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 14, indicating cognitively intact. The assessment also documented his need for total dependence with toilet use and bathing with one-person physical assist. Resident #12 was care planned on 12/11/20 for ADL self-care performance deficits related to limited mobility and musculoskeletal impairment. Approaches included bathing/showering: avoid scrubbing and pat dry sensitive skin, provide sponge bath when a full bath or shower cannot be tolerated, resident is totally dependent on one staff to provide bath/shower per request, schedule, and as necessary. A review of Resident #12's [NAME] dated 9/1/21 revealed: Shower - provide sponge bath when a full bath or shower cannot be tolerated. Resident is totally dependent on one staff to provide bath/shower per request, schedule, and as necessary. (Photographic evidence obtained) Review of the certified nursing assistant (CNA) task documentation revealed Resident #12 received a shower four times between 7/1/21 and 8/31/21. (Photographic evidence obtained) On 9/1/21 at 10:55 AM, Resident #12 was outside his room. He was asked if the staff had given him a Page 1 of 7 105310 105310 09/02/2021 Avante at Ormond Beach, Inc 170 N Kings Road Ormond Beach, FL 32174

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few shower or bath today, he replied, the last time I got a shower was around August 3rd. When he was asked if he refuses to take a shower, he replied, No, I do not. On 9/1/21 at 2:48 PM, an interview was conducted with Employee D, Certified Nursing Assistant who was assigned to take care of Resident #12. She stated, Resident #12 gets a bed bath each day and as needed. He is scheduled to get a shower on Tuesday and Friday during the 3-11 PM shift. If a resident refuses a shower, then we are supposed to document it in the computer and on the shower sheet. On 9/1/21 at 03:28 PM, an interview was conducted with Employee E, LPN/North Wing Unit Manager. She reviewed the north wing shower schedule book and confirmed that Resident #12 was scheduled for Tuesday and Friday during the 3-11 PM shift. She reviewed the completed shower task documentation on the computer and confirmed that for the past thirty days, Resident #12 had only received a shower on 8/17/21, 8/18/21 and 8/26/21. When she was asked if there was any documentation, he refused to take a shower in the past thirty days, she said, Yes, once on 8/17/21. Employee E, LPN stated the aides should be documenting all showers in the computer and confirmed the documentation for Resident #12 was not sufficient to confirm that showers were being provided as scheduled. On 9/2/21 at 11:45 AM, an interview was conducted with the Director of Nursing (DON). She stated that Resident #12 is usually outside smoking until later in the evening and when he comes in, he doesn't want to take a shower. When she was asked what should happen if a resident refuses to take a shower, she stated, staff should document the refusal in the computer and on the shower sheet. The DON reviewed Resident #12's completed shower task documentation sheets for July and August 2021 and confirmed that showers were not being provided as scheduled and there was no documentation that he was refusing them. Review of the facility's Policy and Procedure for Activities of Daily Living (ADLs), revised on 3/2/19, revealed the facility will provide care and services for the following activities of daily living: a. Hygiene bathing, dressing, grooming, and oral care. (Photocopy obtained) . 105310 Page 2 of 7 105310 09/02/2021 Avante at Ormond Beach, Inc 170 N Kings Road Ormond Beach, FL 32174

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 observation, interview, record reviews and a review of the policy and procedure for respiratory care, the facility failed to ensure that one (Resident # 89) of seven residents on oxygen therapy, received the correct number of liters of oxygen ordered by the physician, in a total sample of 33 residents. This could result in the resident not receiving appropriate care and/or clinical complications. Residents Affected - Few The findings include: On 8/30/21 at 2:20 PM, Resident #89 was observed lying in bed with oxygen via nasal cannula. An observation of his oxygen concentrator revealed the oxygen flow was set at 2.5 liters/minute (LPM). A review of Resident #89's medical record noted an admission date of 3/2/21 and a diagnosis of chronic obstructive pulmonary disease (COPD) as well as acute respiratory failure with hypoxia. A review of the physician's order written on 3/3/21 revealed, Oxygen (O2) at 2 LPM/nasal cannula (NC) as needed (prn) for shortness of breath (SOB) O2 oxygen saturation (sat) <92% every 8 hours as needed for SOB. On 9/1/21 at 11:30 AM, Resident #89 was observed lying in bed with oxygen via nasal cannula. An observation of his oxygen concentrator revealed the oxygen flow was set at 3 LPM. (Photographic evidence obtained) On 9/1/21 at 4:09 PM, Resident #89 was observed for a third time in his room with oxygen via nasal cannula. An observation of his oxygen concentrator revealed the oxygen flow was set at 3 LPM. An interview was conducted with Employee G, Licensed Practical Nurse (LPN), and Resident #89's assigned nurse on 9/1/21 at 4:11 PM. When she was asked to check the oxygen setting on Resident #89's oxygen concentrator, she reported it was set at 3 LPM. When she was asked how many LPM the resident was supposed to receive, she replied, 2 LPM and adjusted the oxygen level to 2 LPM. When she was asked who is responsible for checking the oxygen setup, she said, the nurses are responsible for ensuring the correct settings, but she had been off for the last 3 days. A review of the quarterly minimum data set (MDS) assessment, dated 8/10/21, revealed Resident #89 had a Brief Interview for Mental Status (BIMS) score of 7, indicating severely impaired cognition. The assessment also documented he was receiving oxygen and hospice care. A review of Resident #89's care plan revealed, he has oxygen therapy related to COPD, history of respiratory failure, congestive heart failure (CHF), and SOB. Interventions included: change residents position every 2 hours to facilitate lung secretion movement and drainage. Give medications as ordered by physician. Monitor/document side effects and effectiveness. Observe for signs or symptoms of respiratory distress and report to physician PRN. Oxygen settings: Oxygen via nasal cannula per physician orders. A review of the Respiratory/Tracheostomy Care and Suctioning policies and procedures with revised date of 3/2/19, read: The intent of this policy is that each resident receives necessary respiratory care and services that is in accordance with professional standards of practice, the resident's care plan, and the resident's choice. The facility will ensure that a resident, who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with 105310 Page 3 of 7 105310 09/02/2021 Avante at Ormond Beach, Inc 170 N Kings Road Ormond Beach, FL 32174

F 0695 Level of Harm - Minimal harm or potential for actual harm professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences. (Copy obtained) . Residents Affected - Few 105310 Page 4 of 7 105310 09/02/2021 Avante at Ormond Beach, Inc 170 N Kings Road Ormond Beach, FL 32174

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to maintain a medication error rate of less than five percent. During the medication administration observations, there were three errors and a total of thirty-five opportunities, resulting in an error rate of 8.57%. Residents Affected - Some The findings include: On [DATE] at 9:19 AM, an observation of medication administration was conducted with Employee H, Licensed Practical Nurse (LPN). While trying to obtain one loratidine 10 milligram (mg) tablet, three tablets poured into the medication cup. The nurse then used a spoon to separate one pill and disposed the other two loratidine tablets in a trash container attached to the medication cart. During this observation, three residents were close to where the nurse threw out the pills. On [DATE] at 9:30 AM, during an interview with Employee H, LPN, she confirmed the disposal of two loratidine tablets into the garbage container. She stated that since the medication was not a narcotic it was not an issue. When she was asked about the facility policy on medication disposal, she stated that narcotics are disposed in a solution for destroying medication and should be signed off by two nurses. She added, she was not sure about the process for non-controlled medication and that she had always disposed the medication in the garbage bag. On [DATE] at 10:00 AM, an observation of medication administration was conducted for Resident #4 with Employee E, LPN. Resident #4 had a physician's order for calcium acetate (used to prevent high blood phosphate levels in patients who are on dialysis due to severe kidney disease), 667 mg (milligram) capsule, give two capsules by mouth twice a day every Monday, Wednesday and Friday related to end stage renal disease, give with breakfast and dinner. Employee E, LPN administered one capsule of calcium acetate 667 mg to Resident #4, while the resident was in the hallway awaiting transportation to the dialysis center. On [DATE] at 10:06 AM, Employee E, LPN was observed entering room [ROOM NUMBER]-A to administer medication and left the cart unlocked. On [DATE] on 12:50 PM, an interview was conducted with Employee E, LPN. She acknowledged only one calcium acetate 667 mg capsule was administered to Resident #4, instead of the physician's order for two capsules. She also confirmed the medication cart was left unlocked before entering room [ROOM NUMBER]-A. When she was asked about the administration time for the medication, she did not see anything wrong with the time. After reviewing the medication administration record (MAR) for Resident #4, the nurse confirmed the medication was not administered with his breakfast. On [DATE] at 1:45 PM, an interview was conducted with the Director of Nursing (DON) regarding the findings of the medication administration observations. She stated that nurses were required to enter medication orders as they are prescribed to the MAR and if something is not clear, they should consult the physician for order clarification. When she was asked about the orders for Resident #4, she stated, he was to receive calcium acetate 667 mg (Phosphate binder) 2 capsules two times a day on dialysis day and three times a day for non-dialysis days. When asked about the time for administration, she confirmed that the medication should be offered with meals. She stated that since the direction to administer with meals were at the end of the order it was not clear if it was to be administered with meals on non-dialysis day. She added, she would get the nurse practitioner to clarify the 105310 Page 5 of 7 105310 09/02/2021 Avante at Ormond Beach, Inc 170 N Kings Road Ormond Beach, FL 32174

F 0759 Level of Harm - Minimal harm or potential for actual harm order and add breakfast and dinner to the order. When she was asked what the facility policy on medication destruction was, she stated all medication should be disposed in the medication destruction solution. Controlled medication destruction should be witnessed by two nurses and documented. She mentioned that the nurse observed during medication observation thought that only narcotics needed to be destroyed with the medication destruction solution and therefore, an in-service was conducted. Residents Affected - Some A review of the facility's policy and procedure titled, Disposal/Destruction of Expired of Discontinued Medication, last revised on [DATE], read: 13. Wasted medications are defined as medication contaminated or refused that require disposal. Facility should not place wasted medications back in the original containers. 13.2. Wasted single doses of medication for disposal should be disposed of in a manner that limits access to them by authorized personnel or residents. 13.3 wasted single doses of medication may be flushed or placed in public sewage only if permitted by applicable law. (In Florida: A single dose of wasted medication should be secured until the dose is flushes or placed in public sewage.) A review of the facility's policy and procedure titled, Infection Control- Medication Administration, revised [DATE], read: It is the policy of the facility to ensure that appropriate infection prevention and control measures are taken to prevent the spread of infection in accordance with State and Federal Regulation and national guidelines. 4. Verify medication is being provided at the right time per physician orders/medication administration record (MAR), verify dosage, and verify route of administration (i.e., orally, intravenous, or subcutaneous). 5. Verify medication is being provided at the right time per physician orders/ medication administration record. (Copies obtained) . 105310 Page 6 of 7 105310 09/02/2021 Avante at Ormond Beach, Inc 170 N Kings Road Ormond Beach, FL 32174

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations and interviews, the facility failed to store, prepare and serve food in accordance with professional standards for food service safety, by failing to maintain the kitchen in a safe and sanitary manner for the 102 residents who were currently residing in the facility. The findings include: During a visit to the kitchen on 8/30/21 at 10:25 AM, an observation of three air conditioner (AC) vents was found to be dirty and have a black substance on them. The ceiling around each vent was also found to have a black substance. One of the AC vents was near the steam table where food is served. During an interview with Employee A, Certified Dietary Manager at the time of the observation, he confirmed the findings and stated, he would talk with maintenance about it. (Photographic evidence obtained) During a second visit to the kitchen on 8/31/21 at 3:35 PM, two of the three AC vents remained dirty with black substance on them. The ceiling around each vent continued to have a black substance. During an interview with Employee C, Regional Certified Dietary Manager at the time of the observation, he confirmed the vents were not clean and the ceiling needed to be repaired. (Photographic evidence obtained) On 8/31/21 at 3:38 PM, the Administrator entered the kitchen and stated the maintenance staff came in last night and cleaned them. He was shown the vents and confirmed they could be cleaned better. On 9/1/21 at 11:45 AM, the three AC vents were observed dripping water near the serving line, near the food cart and over the dishwashing area. During an interview with Employee B, Dietician at the time of the observation, he confirmed the AC vents were dripping water. (Photographic evidence obtained) On 9/2/21 at 1:30 PM, a follow up visit to the kitchen was conducted with Employee C, Regional Certified Dietary Manager and Administrator. The Administrator stated repairs were made to the air conditioning and ventilation system which appeared to eliminate the dripping condensation from the vents. Administrator also stated, they had plans to make repairs to the ceiling area in the kitchen. . 105310 Page 7 of 7