Inspection·March 1, 2023

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, and record review, the facility failed to ensure respiratory services were provided in accordance with professional standards for 1 of 2 residents reviewed for respiratory care, Resident #45. Residents Affected - Some Findings include: During an observation on 2/26/2023 at 9:33 AM, Resident #45 was in his room seated in a wheelchair, receiving oxygen at 2.5 liters via nasal cannula. During an observation on 2/28/2023 at 8:58 AM, Resident #45 was seated in a wheelchair in his room beside his bed. The oxygen concentrator beside Resident #45's bed was running at 2 liters but was not in use by Resident #45. During an interview on 2/28/2023 at 9:30 AM, after observing Resident #45's room, Staff A, Licensed Practical Nurse (LPN), confirmed that there was an oxygen concentrator in Resident #45's room at his bed side for use by Resident #45. Review of admission Plan of Care note dated 1/20/2023 for Resident #45 reads, The resident has respiratory failure. The resident's lungs are clear. The resident is not receiving oxygen. Review of Daily Skilled Note dated 2/1/2023 for Resident #45 documented that the resident was on oxygen. Review of Resident #45's physician's orders, active orders as of 2/28/2023, showed Resident #45's physician's order for oxygen via nasal cannula had a start date of 2/28/2023. The physician's order for Resident #45 to receive oxygen via nasal cannula was obtained 27 days after the facility documented oxygen therapy had started for Resident #45. During an interview on 2/28/2023 at 9:20 AM, Staff A, LPN, confirmed Resident #45 did not have an active physician's order to be administered oxygen. During an interview on 2/28/2023 at 9:37 AM, the Director of Nursing confirmed Resident #45 did not have an active physician's order or a discontinued physician's order to be administered oxygen. Review of the facility policy and procedure titled General Dose Preparation and Medication Administration last revised on 1/1/2022 and last reviewed on 1/19/2023, reads, Procedure . 4. Prior to administration of medication, Facility staff should take all measures required by Facility policy and Applicable Law, including, but not limited to the following: 4.1 Facility staff should: 4.1.1 Verify (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 5 Event ID: 105333 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at MT Dora, Inc 3050 Brown Ave Mount Dora, FL 32757 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)