Health inspection·April 27, 2023

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observations, medical record review, interviews, and a review of the facility's policy and procedure for pressure ulcers, the facility failed to ensure that a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing, by failing to apply physician-ordered bilateral heel protectors for one (Resident #88) of two residents selected for a review of pressure ulcers, out of nine residents with pressure ulcers, from a total sample of 43 residents. Residents Affected - Few The findings include: An observation of Resident #88 was made on 4/24/23 at 11:57 a.m. He was in is his room. A family member was at bedside and was interviewed concerning the resident's care. She stated the resident had dressings on both heels for pressure ulcers and was receiving hospice services. His dressings were always done and the wound care physician saw him. The family member's concern was that Resident #88 had two sets of booties/heel protectors for his feet and they had both disappeared. They have been missing for at least three weeks. She stated she had searched the room numerous times. Dressings were observed on both heels, but there were no heel protectors applied. Resident #88 was observed on 4/25/23 at 8:30 a.m. lying in his bed. Dressings were observed on both heels, however, no booties/heel protectors were applied, nor was a pillow under his ankles to offload the pressure to his heels. Resident #88 was observed on 4/26/23 at 8:49 a.m. lying in his bed. Dressings were observed on both heels, however, no booties/heel protectors were applied, nor was a pillow under his ankles to offload the pressure to his heels. His right foot was hanging off the side of the bed. The resident's family member was interviewed again on 4/26/23 at 12:00 p.m. She stated again that Resident #88 had not had his booties/heel protectors for several weeks and there were two pairs that were ordered by the hospice provider. She stated, He does not have them on again today. A review of Resident #88's medical record revealed an admission date of 4/15/22 with diagnoses including cerebrovascular accident (CVA - stroke), hemiplegia (weakness/immobility on one side), and diabetes mellitus. The resident was noted with an acquired pressure ulcer on his right heel on 8/12/22, and his left heel on 10/5/22. Wound dressings were ordered and dated 4/25/23. A review of the resident's active physician's orders revealed an order for bilateral heel booties every shift for heel protection, dated 8/16/22. A new order was placed on the chart on 4/27/23, instructing staff to 'Float heels using either prevention boots or other offloading boots or pillows being sure the patient's heels are not touching the pillow or directly on the mattress while in bed.' Page 1 of 6 105310 105310 04/27/2023 Avante at Ormond Beach, Inc 170 N Kings Road Ormond Beach, FL 32174

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of a Wound Progress note, dated 4/25/23, revealed a right heel wound, Stage IV, with bone exposed and a left heel wound, Stage III. The right heel was improving but the left heel was not improving, it was staying the same. An interview was conducted with Certified Nursing Assistant (CNA) B on 4/26/23 at 2:02 PM. She stated the resident used a mechanical lift to transfer, he did not stand, and he required total assistacen from staff for transfers and toileting. He could feed himself. She stated he did have pressure ulcers on his heels, and his heels should be offloaded. He did take his feet off of the pillow when she tried to use one. She reported she was not aware of booties/heel protectors having been ordered for this resident. If he is turned on one side, he will turn right onto his back. I have been trying to offload his heels, but he likes to have one foot off the bed. She reported not seeing any boots/booties/heel protectors for his feet. An interview was conducted with Licensed Practical Nurse (LPN) C on 4/26/23 at 2:07 PM. She reported being unable to find any booties/heel protectors in the resident's room, and that the CNA just asked her about the resident's heel booties. The LPN stated the booties would have to be ordered. The Central Supply clerk came by and reported that heel booties were available in supply. LPN C stated, He (Resident #88) is supposed to have heel protectors on, and I will put them on as soon as I receive them. The LPN confirmed he was not currently wearing the booties to protect his heels. A review of the facility's policy and procedure for Treatment Services to Prevent/Heal Pressure Ulcers (Revised 3/2/19), read: The facility will ensure a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers. A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice to promote healing, prevent infection and prevent new ulcers from developing. . 105310 Page 2 of 6 105310 04/27/2023 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, and interviews, the facility failed to ensure that three (Residents #42, #8, and #18) of 12 residents receiving oxygen, from a total sample of 43 residents, had physicians' orders for the oxygen (Resident #42), and received oxygen at the flow rate ordered by the physician (Residents #8, and #18). Residents Affected - Few The findings include: 1. On 4/24/23 at 2:45 p.m., Resident #42 was observed lying in bed wearing a nasal cannula. His oxygen concentrator was located at bedside, and the oxygen flow rate was set at 3 LPM. (Photographic evidence obtained) A review of Resident #42's physician's orders revealed no order for oxygen. (Photographic evidence and copy obtained) A medical record review revealed that Resident #42 was admitted to the facility on [DATE] and then readmitted on [DATE]. His diagnoses included COPD with (acute) exacerbation; dependence on supplemental oxygen; shortness of breath; generalized anxiety disorder, and major depressive disorder. A review of the April 2023 Medication Administration Record (MAR) revealed no oxygen monitoring. (Copy obtained) A review of the Quarterly Minimum Data Set (MDS) assessment, dated 3/29/23, revealed Resident #42 had a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15 points, indicating Resident #42 was cognitively intact. The assessment also documented that he was receiving oxygen therapy. A review of Resident #42's care plan, with a revision date of 1/17/23, revealed he had oxygen therapy related to COPD and shortness of breath (SOB). Interventions included administration of medications as ordered by the physician. Monitor/document side effects and effectiveness. Oxygen settings. Oxygen via nasal cannula per Medical Doctor (MD) orders. On 4/27/23 at 11:11 a.m., LPN D reported that nursing was responsible for ongoing monitoring of oxygen therapy, ensuring the resident was provided the correct flow rate and weekly oxygen tube changes. Correct oxygen settings were identified on the order in the electronic medical record. Correct oxygen settings were communicated from one staff person to another in shift change reports. When asked what happened when there were discrepancies found in residents' physicians' orders, he replied, Call the nurse practitioner and clarify the order, review what the order states, review changes that need to be made, and correct the order. On 4/27/23 at 11:22 a.m., the Director of Nursing (DON) confirmed that Resident #42's correct oxygen flow rate settings were identified in the physician's order in [the electronic medical record]. 2. On 4/24/23 at 1:58 p.m., an observation was made of Resident #8 lying in bed with oxygen being provided via nasal cannula. The oxygen flow rate was set at 3 Liters per minute (LPM). When the resident was asked what her flow rate setting should be, she was unsure. (Photographic evidence obtained) 105310 Page 3 of 6 105310 04/27/2023 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 Residents Affected - Few An observation was made of the resident lying in her bed on 4/25/23 at 8:30 a.m. Her oxygen flow rate was still set at 3 LPM. (Photographic evidence obtained) An observation was made of the resident lying in her bed on 4/26/23 at 8:33 a.m. Her oxygen flow rate was still set at 3 LPM. At 9:55 a.m. on 4/26/23, her oxygen flow rate was set at 2 LPM. (Photographic evidence obtained) A medical record review was conducted, which noted an admission date of 6/25/20 with a readmission on [DATE]. The resident's diagnoses included chronic obstructive pulmonary disease (COPD) and hypoxemia. A 3/16/23 physician's order noted the resident's oxygen flow rate was to be set at 2 LPM via nasal cannula. The resident's care plan, updated on 2/20/23, revealed a focus area for emphysema and COPD. Oxygen was to be administered as ordered by the physician. An interview was conducted with Licensed Practical Nurse (LPN) A on 4/26/23 at 10:00 a.m. The LPN reviewed Resident #8's oxygen order in the electronic medical record and reported the oxygen should be infusing at 2 LPM. She stated she hadn't changed the oxygen setting this morning. She entered the resident's room and checked the oxygen concentrator to ensure that the oxygen flow rate was set at 2 LPM. When she was shown the photographs of the resident's oxygen setting over the last three days (3 LPM), she stated the oxygen setting in the photographs was inaccurate and the staff must not be getting at eye level when setting the flow rate. A review of the facility's policy and procedure for Respiratory/Tracheostomy Care and Suctioning (Revised 3/26/21), read: The facility will ensure residents who need respiratory care are provided such care consistent with professional standards of practice, the comprehensive person centered care plan, and resident goals and preferences. Under number 4 was written: Based upon the resident assessment attending physicians orders, and professional standards of practice, the facility in collaboration with the resident/resident's representative will develop a care plan that includes appropriate interventions for respiratory care. 3. A review of the medical record revealed that Resident # 18 was admitted to the facility on [DATE], with diagnoses including COPD with acute exacerbation, generalized anxiety disorder, and major depressive disorder. On 4/24/23 at 11:39 a.m., the resident's oxygen concentrator was observed to be set at a flow rate of 4 LPM. The resident verbalized the flow rate should be set at 2 LPM and expressed she did not adjust the flow rate herself. She reported she was not physically capable of reaching the dial to adjust the flow rate. On 4/25/23 at 10:30 a.m., the resident's oxygen flow rate was observed to be set at 4 LPM. On 4/26/23 at 11:47 a.m., the resident's oxygen flow rate was observed to be set at 3 LPM. On 4/26/23 at 2:46 p.m., the resident's oxygen flow rate was observed to be set at 2 LPM. On 4/27/23 at 1:52 p.m., LPN E explained that the resident's oxygen was ordered at 2 LPM PRN (as needed) and was administered for low oxygen saturation. She reviewed the resident's record and verified the record documented an oxygen order for a flow rate of 2 LPM PRN and for oxygen saturations below 90. She expressed she was not aware that the resident's oxygen was set at a flow rate of 3 or 4 LPM, and explained that CNAs did not adjust flow rates, as oxygen was considered a medication and CNAs 105310 Page 4 of 6 105310 04/27/2023 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 Residents Affected - Few did not administer medications. If a CNA observed an oxygen flow rate set outside of the prescribed amount, they should report it to the nurse. Nurses should be checking oxygen flow rates during medication passes. A review of Resident #18's physician's orders revealed an order written on 3/28/23 for oxygen at two liters per minute via nasal cannula PRN for shortness of breath and oxygen saturations below 90. An order written on 4/25/23 required oxygen saturations to be taken every shift and PRN. Call medical doctor (MD) if saturations are below 90. . 105310 Page 5 of 6 105310 04/27/2023 Avante at Ormond Beach, Inc 170 N Kings Road Ormond Beach, FL 32174

F 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observation and interviews, the facility failed to post the following Nurse Staffing information on a daily basis as required: Residents Affected - Few (i) Facility name. (ii) The current date. (iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: (A) Registered nurses. (B) Licensed practical nurses or licensed vocational nurses (as defined under State law). (C) Certified nurse aides. (iv) Resident census. During a tour of the facility on 4/24/23 at 11:13 a.m., the Daily Staffing Projection posted in a shadow box near the entrance of the facility was observed. The date of the Nurse Staffing information was 3/20/23. (Photographic evidence obtained) During an interview with Workforce Coordinator F on 4/27/23 at 10:19 a.m., she stated she had been performing her duties since October 2022. She stated she was responsible for posting the daily staffing projection, and in her absence, the Senior Human Resource Manager was responsible for ensuring the information was updated. She was advised of the 4/24/23 observation of the out-of-date posted staffing information and she acknowledged it was out of date. She stated she had been on leave starting the day after that information was posted, she recently returned to work, and the staffing information had since been corrected. During an interview with the Senior Human Resources Manager on 4/27/23 at 10:36 a.m., he stated he was aware of the requirement for the daily posted staffing. He confirmed that Workforce Coordinator F was responsible for updating the daily posted staffing and that he served as a back-up in her absence. He stated she had been out on leave and he was not aware that the staffing had not been changed. . 105310 Page 6 of 6