Health inspection·June 26, 2023

F 0885 Report COVID19 data to residents and families. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to accurately inform resident representatives, and families of those residing in the facility of the current COVID-19 status for 4 of 5 sampled residents (Residents #1, #2, #4 and #5) out of a total of 103 residents in the facility. On 6/23/23, the facility communicated to resident representatives/family members there were no staff or residents positive for COVID-19 at the facility, when in fact there were residents in the facility who were COVID-19 positive. Residents Affected - Many The findings include: During an entrance conference with the Administrator and the Infection Preventionist (IP) on 6/26/23 at 9:05 am, the IP reported there was an active COVID-19 outbreak in the building. Positive residents were cohorting on the south wing. Six residents were coming off isolation today and there were a total of 15 positive residents at this time. A line listing was requested for all positive residents identified during the outbreak. Census at the time was 103 residents. Review of the COVID-19 resident line list revealed on 6/6/23, the first 6 resident tested positive for COVID-19. Between 6/8/23 and 6/23/23 an additional 28 residents tested positive for COVID-19; fifteen of those residents within the past 10 days. A tour of the facility was conducted on 6/26/23 at 9:35 am. The south wing was toured first and revealed multiple resident rooms with signage and personal protective equipment (PPE) for droplet and contact isolation. Housekeeping was in one room wiping down the room and the doorknob. She had full PPE on. A second staff was observed outside another room donning full PPE prior to entering. Licensed Practical Nurse (LPN) A was interviewed at 9:45 am. She said, The COVID positive residents are mostly on this one side of the unit, but there are residents everywhere and that is why the COVID keeps spreading. Certified Nursing Assistant (CNA) A was interviewed on 6/26/23 at 10:05 am. She said the COVID-19 outbreak started about 3 weeks ago and quite a few staff had also tested positive. An interview was conducted with Resident #1 on 6/26/23 at 10:15 am. She and Resident #3 were outside smoking on the south end of the front patio. There were multiple residents also smoking on the north side of the patio, approximately 50 to 60 feet away. Resident #1 introduced herself and said everyone caught COVID because one resident who was admitted with COVID wouldn't stay in her room. Resident #1 tested positive herself last Sunday. She is allowed to come to this side of the patio to smoke but must wear a mask in the halls. Resident #1 stated she comes off isolation tomorrow. She concluded by stating the facility called her brother to report the COVID status of the building and told Page 1 of 3 105310 105310 06/26/2023 Avante at Ormond Beach, Inc 170 N Kings Road Ormond Beach, FL 32174

F 0885 him there were no positive cases, and he could visit. But they still have positive cases in the building! Level of Harm - Minimal harm or potential for actual harm Resident #3 was interviewed on 6/26/23 at 10:30 am and reported she had tested positive for COVID-19 but felt fine. She is allowed to come outside and smoke away from the general population as long as she wears a masks in the halls. She showed me her N95 mask on which she had drawn a smiley face. Before she got sick. she had been wearing a mask and staying away from people, but still caught it and tested positive Sunday. Residents Affected - Many A review of Resident #1's electronic medical record (EMR) found she was admitted to the facility on [DATE] and had diagnoses including COVID-19 (diagnosed 6/18/23). A review of her admission Minimum Data Set (MDS) assessment dated [DATE] revealed she had a brief interview for mental status score of 15, indicating she was cognitively intact. Resident #1 had a physician's orders dated 6/18/23 for contact and droplet precautions for COVID-19 for 10 days, ending 6/28/23. Resident #1's electronic Cliniconex Message Board transcripts (a blast messaging program that notifies the next of kin or resident representative of the COVID-19 facility status upon activation by a user) were reviewed. The text message and phone calls dated 6/23/23 to Resident #1's emergency contact announced: We are calling to inform you that there are no staff or residents positive for COVID-19 at the facility. Our center is following the recommendations of the CDC (Centers for Disease Control) on prevention steps. Visitation is still open at this time. The notifications were sent by the Administrator. (Photographic evidence obtained) Resident #3's EMR was reviewed and revealed she was admitted on [DATE] and readmitted [DATE]. She had diagnoses including COVID-19 (diagnosed 6/23/23). Her Cliniconex Message Board transcripts revealed the last message was sent to her emergency contact on 6/16/23 and reported 1 or more individuals in the building were positive for COVID-19. There was no message sent on 6/23/23, the day of her readmission. Additional residents were reviewed including Resident #4 (admitted [DATE]), Resident #2 (admitted [DATE]) and Resident #5 (admitted [DATE]). All 3 residents Cliniconex messages sent by the Administrator on 6/23/23 to their emergency contacts announced no COVID-19 in the building. (Photographic evidence obtained) The Administrator was interviewed on 6/26/23 at 11:50 am. She was asked about the Cliniconex notifications sent on 6/23/23. The Administrator confirmed on 6/23/23, she had sent a blast message to all resident contacts all at once. When advised the message reported no COVID-19 in the building despite having 15 active cases that day per the resident line list, she said that was a mistake. She reviewed the electronic site and showed the notification status selection buttons were right next to each other, that she must have selected the wrong message button. She had no idea that message had gone out. The Administrator confirmed the same message went out to all resident's contacts in a batch, stating she would correct it right now. The messages are sent every week. The facility's COVID-19 Preparedness Plan 2023 stated under Section IX states: Residents and families are provided weekly updates on outbreak status. (Photographic evidence obtained) 105310 Page 2 of 3 105310 06/26/2023 Avante at Ormond Beach, Inc 170 N Kings Road Ormond Beach, FL 32174

F 0885 . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 105310 Page 3 of 3