Health inspection·February 23, 2024

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and facility policy review, the facility failed to ensure enteral tube syringes were replaced daily for four (Residents #4, #8, #6, and #7) of five residents receiving enteral tube feedings (TF) and failed to ensure the enteral feeding bag for one (Resident #7) resident receiving enteral TF was dated/timed to reflect contents were less than or up to 24 hours old for residents, from a total sample of 8 residents. This could result in the residents not receiving appropriate care and/or clinical complications. The findings include: 1. On 2/22/24 at 10:25 AM, Resident #4 was observed supine in bed, with head of bed (HOB) elevated between 30 and 45 degrees. Her TF syringe was on an overbed table, not dated. (Photographic evidence obtained) A review of the medical record for Resident #4 revealed she was admitted on [DATE] with diagnoses that included anoxic brain damage, diabetes type 2, tracheostomy, and gastrostomy. Resident's enteral feed order dated 2/1/24, revealed every shift Diabetisource 1.2 @ 65 ml/hr. x20 hrs. on at 1400, off at 1000. A review of the most recent minimum data set (MDS) assessment, dated 2/6/24, revealed the resident was comatose and totally dependent for all care. Physician's order dated 1/1/24 revealed change enteral syringe every 24 hours and as needed. (Copy obtained) During an interview with Licensed Practical Nurse (LPN) A on 2/22/24 at 11:05 AM, she was asked who was responsible for changing TF supplies. She replied, the 11-7 shift was responsible to change out the TF bags/solution and syringe, and they are supposed to be dated. 2. On 2/22/24 at 12:35 PM, Resident #8 was observed in bed with eyes closed. Her TF was dated 2/22/24. A review of the medical record for Resident #8 revealed she was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus with diabetic neuropathy, anemia, hemiplegia and hemiparesis, tracheostomy, and gastrostomy status. Resident's enteral feed order dated 12/18/23, revealed every shift recommend Diabetisource 1.2 @ 100 ml/hr. x20 hrs., on at 12 pm, off at 8 am flush 50 ml/hr. every 4 hr. A review of the most recent MDS assessment dated [DATE], revealed, not comatose, clear speech, adequate hearing and vision, understands and is understood, with a brief interview for mental status (BIMS) score of 15 out of 15, indicating cognitively intact. Physician's order dated 2/3/24 revealed change enteral syringe every night shift. (Copy obtained) Page 1 of 7 105310 105310 02/23/2024 Avante at Ormond Beach, Inc 170 N Kings Road Ormond Beach, FL 32174

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 3. On 2/22/24 at 12:45 PM, Resident #6 was observed in bed with HOB elevated. His TF syringe was on an overbed table, not dated. (Photographic evidence obtained). A review of the medical record for Resident #6 revealed he was admitted on [DATE] with diagnoses that included gastrostomy status, aphasia following cerebral infarction, hemiplegia, severe protein-calorie malnutrition, and type 2 diabetes mellitus. Resident's enteral feed order dated 9/11/23, revealed every shift Diabetisource 1.2 at 45ml/hr. x 20 hrs., on at 2 pm, off at 10 am. Resident's review of the most recent MDS assessment, dated 1/9/24, revealed the resident had severe hearing impairment but has a cochlear implant, impaired vision but can see large print, is rarely understood but understands simple commands and responds appropriately, not comatose; unable to assess BIMS due to verbal difficulties. Physician's order dated 2/10/24, revealed change enteral syringe every night shift. (Copy obtained) 4. On 2/22/24 at 12:50 PM, Resident #7 was observed in bed, eyes closed; lips were dry and crusted, TF pump was off, Isosource bag was dated 2/21/24 (photo), resident did not respond to verbal stimuli. His TF syringe was on an overbed table, not dated. (Photographic evidence obtained). A review of the medical record for Resident #7 revealed he was admitted on [DATE] with diagnoses that included hemiplegia and hemiparesis, dysphagia, oropharyngeal phase, and aphasia. Resident's enteral feed order dated 5/9/23, revealed every shift Isosource 1.5 at 65 ml/hr. x 20 hrs. off 1000, on 1400. A review of the most recent MDS assessment dated [DATE], unclear/garbled speech, usually understands and is sometimes understood, not comatose, unable to conduct BIMS due to garbled speech. Physician's order dated 2/9/24, revealed change enteral syringe every night shift. (Copy obtained) On 2/22/24 at 3:56 PM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC revealed that the tube feeding was a closed system. The bags are prefilled and are usually changed out on the night shift. When asked why the TF would be dated with yesterday's date, she replied, most likely because the 24 hours wasn't up. When asked how anyone would know if the bags did not have a time hung on them. She stated, the bags can actually be hung for 36 hours and would be changed out by then. When asked how they could be sure, the RNC did not respond. A review of the facility's policies and procedures titled: Quality of Care (revised 3/2/19), revealed the following: Page 3-4, Item 10. Tube feeding Management/Restore Eating Skills. The facility will ensure that a resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident's clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and a resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including by not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. (Copy obtained) . 105310 Page 2 of 7 105310 02/23/2024 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, interviews, and medical record review, the facility failed to ensure tracheostomy/respiratory care was provided to two (Residents #4 and #8) of two resident reviewed for respiratory care, by failing to follow physician orders for tracheostomy care, suction and/or oxygen tubing. This could result in the residents not receiving appropriate care and/or clinical complications. Residents Affected - Few The findings include: 1. A review of the medical record for Resident #4 revealed she was admitted on [DATE] with diagnoses that included anoxic brain damage, diabetes type 2, tracheostomy, and gastrostomy. A review of the most recent minimum data set (MDS) assessment, dated 2/6/24, revealed the resident was comatose and totally dependent for all care and unable to assess Brief Interview for Mental Status (BIMS). On 2/22/24 at 10:25 AM, Resident #4 was observed supine in bed (lying on her back), with head of bed elevated between 30 and 45 degrees. A tracheostomy collar was in place with oxygen (O2) flow set at 12 liter per minute (LPM). The tracheostomy collar was humidified and corrugated tubing with drain bag attached to the bed frame higher than the tubing causing excess water to pool in tubing rather than drain bag (and was not dated). The suction setup located on bedside table revealed the tubing was open to air, was not bagged and was dated 2/7/24. The sterile water bottle on overbed table at foot of bed was open to air and was not dated. One time use cardboard with plastic liner suction container was observed on overbed table with clear fluid. (Photographic evidence obtained) Review of Resident #4's physician's orders revealed the following: 1/1/24-Trach-resident has 8.5 trach; obtain O2 sats every shift, notify Medical Doctor of (oxygen) saturations <90%; humidified oxygen 28%/ 5 liters per minute via trach collar; may suction every 2 hours as needed. 1/6/24-Change corrugated tubing and trach mask weekly every Saturday night shift. 1/6/24-Change humidity bottle weekly every Saturday night shift. 1/1/24-Change internal cannula daily. 1/1/24-Change nebulizer set-up weekly every Saturday night shift. 1/6/24-Change O2 tubing connecting to O2 concentrator every Saturday night shift. 1/6/24-Change suction cannister and tubing weekly every Saturday night shift. 1/6/24-Change yanker suction weekly every Saturday night shift. On 2/22/24 at 11:05 AM, an interview was conducted with Licensed Practical Nurse (LPN A). She stated that trach collars are changed weekly, and inner cannula are changed daily. She explained that she performed this task when she first comes on duty. The bedside suction machine with tubing is changed weekly at night but cannister is only changed when full. The suction kits are for one-time use only and the sterile water is to be dated after being opened. The trach collar is to be at 28% or 8 105310 Page 3 of 7 105310 02/23/2024 Avante at Ormond Beach, Inc 170 N Kings Road Ormond Beach, FL 32174

F 0695 LPM; is humidified with tubing changed weekly with tubing to be at lowest point of gravity. Level of Harm - Minimal harm or potential for actual harm 2. A review of the medical record for Resident #8 revealed she was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus with diabetic neuropathy, anemia, hemiplegia and hemiparesis, tracheostomy, and gastrostomy status. A review of the most recent MDS assessment dated [DATE], revealed, not comatose, clear speech, adequate hearing and vision, understands and is understood, with a BIMS score 15 of 15, indicating cognitively intact. Residents Affected - Few On 2/22/24 at 12:35 PM, Resident #8 was observed in bed, eyes closed, roused to verbal stimuli; nasal cannula in place; O2 tubing not dated, O2 set at 2.5 LPM. (Photographic evidence obtained) Review of Resident #8's physician's orders revealed the following: 12/9/23-Change oxygen set up and bag weekly, every Sunday night shift, place in labeled O2 bag and tie to handle of O2 concentrator. 1/25/24-Oxygen continuous at 2 LPM via nasal cannula. On 2/22/24 at 1:45 PM, a joint interview was conducted with the Director of Nursing (DON) and the Regional Nurse Consultant (RNC). They explained the O2 tubing is changed weekly by nurses on the night shift and is to be dated. Nurses are responsible to check liter flow every shift and certified nursing assistants (CNA) are not allowed to adjust liter flow. A review of the facility's policies and procedures titled: Quality of Care (revised 3/2/19), revealed the following: Page 4, Item 12. Respiratory/Tracheostomy Care and Suctioning, The facility will ensure that residents who need respiratory care, including tracheostomy care and tracheal suctioning, is provide such care consistent with professional standards of practice, the comprehensive person-centered care plan and resident goals and preferences. (Copy obtained) . 105310 Page 4 of 7 105310 02/23/2024 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 observations and interview, the facility failed to ensure current and accurate nurse staffing information was posted (facility name, the current date, 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) on a daily basis at the beginning of each shift. Residents Affected - Few The findings include: On 2/22/24 at 9:00 AM, the posted nurse staffing information was observed displayed on a table across from the reception desk. The staffing information was dated 2/21/24 with a census of 99. (Photographic evidence obtained) On 2/22/24 at 10:05 AM, a second observation of the posted staffing information (in the same area) located across from the reception desk was dated 2/21/24 with a census of 99. On 2/23/24 at 9:15 AM, the posted staffing information was observed displayed on the reception desk. The staffing information was dated 2/22/24 with a census of 94. (Photographic evidence obtained) On 2/23/24 at 9:54 AM, the posted staffing information was observed to have been moved from the reception desk to the table across from desk. The form was dated 2/22/24 with a census of 94. On 2/23/24 at 10:40 AM, the posted staffing information observed for a second time on table across from reception desk. The form was observed dated 2/22/24 with a census of 94. On 2/23/24 at 11:00 AM, an interview was conducted with the Administrator. When asked what the current census was for the day, he stated, 96. When asked who updates the daily posted staffing, he stated, The staffing coordinator does. When asked when the daily staffing should be posted/updated. He stated early morning, Before our morning meeting, which is held at 9:00 AM. It should be updated around 7:45-8:00 AM, then we can discuss it during morning meeting and make any updates if necessary. . 105310 Page 5 of 7 105310 02/23/2024 Avante at Ormond Beach, Inc 170 N Kings Road Ormond Beach, FL 32174

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. 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 ensure three (Resident #6, #7, and #8) of eight sampled residents had access to the call light while in bed. Residents Affected - Few The findings include: 1. On 2/22/24 at 12:45 PM, Resident #6 was observed in bed with head of bed elevated, resident did not speak but nodded his head after greeting the resident. The call light was clipped to itself on the wall. (Photographic evidence obtained). When asked if he could get to his call light, the resident shook his head in a no response. A review of the medical record for Resident #6 revealed he was admitted on [DATE] with diagnoses that included gastrostomy status, aphasia following cerebral infarction, hemiplegia, severe protein-calorie malnutrition, and type 2 diabetes mellitus. A review of the resident's most recent minimum data set (MDS) assessment dated [DATE] revealed, severe hearing impairment with a cochlear implant, impaired vision but can see large print, is rarely understood but understands simple commands and responds appropriately, not comatose; unable to assess Brief Interview for Mental Status (BIMS) due to verbal difficulties. On 2/23/24 at 9:45 AM, Resident #6 was observed lying in bed, eyes open. His call light was observed clipped to itself on the wall behind his bed, out of his reach. When asked if he could reach his call light if he needed to call for help. He did not answer verbally, he was observed to shake his head in a no response. 2. On 2/22/24 at 12:42 PM, Resident #7 was observed in bed, eyes closed; lips were dry and crusted, call light button was lying on the floor, clipped to the top sheet (Photographic evidence obtained). The resident did not respond to verbal stimuli. A review of the medical record for Resident #7 revealed he was admitted on [DATE] with diagnoses that included hemiplegia and hemiparesis, dysphagia, oropharyngeal phase, and aphasia. A review of the most recent MDS assessment dated [DATE], revealed unclear/garbled speech, usually understands and is sometimes understood, not comatose, unable to conduct BIMS due to garbled speech. On 2/22/24 at 3:45 PM, an interview was attempted with Resident #7 in his room. After greeting the resident, he attempted to speak. His speech was garbled, but he was able to indicate that he was not able to reach/find his call light. The call light remained on the floor. (Photographic evidence obtained). 3. On 2/22/24 at 10:50 AM, an interview was conducted with Certified Nursing Assistant (CNA) A regarding call lights. She explained that CNAs are to supposed to make sure the residents have their call lights within reach every time they go into the room. On 2/22/24 at 12:35 PM, Resident #8 was observed in her bed. The call light was draped over the night stand not within reach (Photographic evidence obtained) When the resident was asked where her call light was, she pointed to night stand and stated, They always forget to give it back to me. A review of the medical record for Resident #8 revealed she was admitted on [DATE] with diagnoses 105310 Page 6 of 7 105310 02/23/2024 Avante at Ormond Beach, Inc 170 N Kings Road Ormond Beach, FL 32174

F 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few that included type 2 diabetes mellitus with diabetic neuropathy, anemia, hemiplegia and hemiparesis, tracheostomy, and gastrostomy status. A review of the most recent MDS assessment dated [DATE], revealed, not comatose, clear speech, adequate hearing and vision, understands and is understood, with a brief interview for mental status (BIMS) score 15 of 15, indicating cognitively intact. On 2/22/24 at 1:45 PM, a joint interview was conducted with the Director of Nursing (DON) and Regional Nurse Consultant (RNC) regarding call lights. During the interview, they stated that all staff should make sure the resident has access to their call light. On 2/22/24 at 2:40 PM, during an interview with Licensed Practical Nurse (LPN) B, she stated that it was everyone's responsibility to make sure call lights were within the residents' reach. On 2/22/24 at 3:00 PM, during an interview with CNA B, she stated that anytime a staff member goes into the residents room, they are supposed to check to see that the call light is withing the residents reach. On 2/22/24 at 3:27 PM, CNA C was asked who is responsible to make sure call lights are within reach, she replied All of us. On 2/22/24 at 4:30 PM, an interview was conducted with the administrator regarding the call light Performance Improvement Project (PIP) initiated in January 2024. The administrator was asked to provide a copy of plan, he replied, he would need to look for it. The PIP was received on 2/22/24 at 10:56 PM. After reviewing the document, the plan did not include a plan for education/in-service to staff or how deficiencies would be addressed. A review of facility Performance Improvement Project: Call lights: Initiated on 1/15/24 revealed: Objective and Goal: Staff responsiveness to patient -initiated call lights is highly important 2. Call light audits will be reviewed for and within the residents reach for safety (Ongoing) 105310 Page 7 of 7