Health inspection·February 14, 2024

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to honor a residents choices for being out of bed for 2 of 4 residents sampled for choices (Residents #37 and Resident #56); failed to honor resident's choice for eating in the Dining room for 3 of 4 residents reviewed for choices (Resident #56, Resident #22, and a resident that wished to remain anonymous); and failed to honor residents choices for showers for 1 of 4 residents sampled for choices (Resident #38). The findings included: 1a). Resident #56 was initially admitted to the facility on [DATE], According to a quarterly MDS, dated [DATE], Resident #56 had a BIMS score of 15, indicating the resident was 'cognitively intact'. The MDS documented that the resident was dependent upon staff for ADLs except for eating. Resident 356's diagnoses at the time of the assessment included: Hemiplegia, Seizure disorder, Anxiety disorder, Depression, Epilepsy. Resident #56's care plan, initiated on 02/11/24, documented, Resident has indicated the following daily preferences are important to her: [Resident #56] prefers to stay in bed on weekend. noted by the MDS Coordinator. The goal of the care plan was documented as, the resident's daily preferences will be honored through the next review date 02/11/24 with a target date of 04/13/24. Interventions to the care plan included: *Offer to assist to get out of bed as per resident preference. *Reevaluate as needed for change in daily preferences. Resident #56's Care plan for Activities of Daily Living (ADLs), initiated on 08/11/21 with a revision date of 10/05/22, documented, Resident has ADL self-care performance deficit related to decreased motility. Requires set-up to total assist of 1 or more persons. Ability varies, diagnoses hemiplegia, obesity, Seizures, Anxiety and generalized weakness. The goal of the care plan was documented as, The resident will maintain current level of function through the review date created on 08/11/22 with a revision date of 12/14/23 and a target date of 04/13/24. Page 1 of 51 105372 105372 02/14/2024 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0561 Interventions to the care plan included: Level of Harm - Minimal harm or potential for actual harm The resident requires a Hoyer Mechanical lift with two or more staff assistance for transfers. Residents Affected - Few On 02/11/24 at 1:27 PM Resident #56 was observed in bed. The resident called this surveyor into the room and stated that she had not been changed all day and had not been out of bed. During a follow up interview with Resident #56, on 02/12/24 at 11:02 AM, Resident #56 stated that she was not assisted out of bed the previous day until approximately 2:00 PM. Resident stated usually they don't get me out of bed at all (referring to being out of bed on the weekends). During an interview with members of the Resident Council, on 02/12/24 at 2:30 PM, including Resident #56, Resident #56 stated, they didn't get me out of bed today until it was time to get me to the meeting. During an interview with the MDS Coordinator, on 02/13/24, at approximately 2:00 PM, the MDS Coordinator stated that the resident preferred to be in bed all weekend, as documented in the care plan. During an interview, on 02/13/24 at 4:44 PM, with Resident #56, when asked about being out of bed, Resident #56 replied, Partly my choice and partly because the CNA says that they don't want to get me up because they are tired or don't feel like it. I used to get up every Sunday through Friday, and on Saturdays I would take to rest. Sunday to Friday I want to be out of bed at 10:30 every morning. I am the only one on this hall that gets up every day. When asked about the care plan that documented her preference for being in bed all weekend, Resident #56 replied, My care plan meeting was last Wednesday and I have never said that I want to be in bed all weekend. She was never there (referring to the MDS Coordinator). We talked about nothing. They asked me about the food and about how I am feeling and if I want to hurt myself. She was not there. 1b). Resident #37 was initially admitted to the facility on [DATE]. According to a Medicare 5-day Minimum Data Set (MDS), dated [DATE], Resident #37 had a Brief Interview for Mental Status (BIMS) score of 14, indicating that the resident was 'cognitively intact'. The MDS documented that Resident #37 was dependent upon staff for Activities of Daily Living (ADLs) except for eating and oral hygiene. Resident #37s diagnoses at the time of the assessment included: Respiratory failure with hypoxia or hypercapnia, Hemiplegia, Seizure disorder, Malnutrition, Adjustment disorder with depressed mood, Functional Quadriplegia, Tracheostomy status, Gastrostomy status, Cerebral infarction, Hemiplegia following cerebral infarction affecting left nondominant side. Resident #37's care plan for activities, initiated 01/11/24, documented, the resident is independent for meeting emotional, intellectual, physical and social needs noted by the Activities Director. The goal of the care plan was documented as, The resident will maintain involvement in cognitive stimulation social activities as desired through review with a target date of 03/20/24. Interventions to the care plan included: *All staff to converse with resident while providing care. *Encourage ongoing family involvement. Invite the resident's family to attend special events, activities, meals. 105372 Page 2 of 51 105372 02/14/2024 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 02/12/24 at 12:12 PM, Resident #37 was observed in her wheelchair wearing a hospital gown. When asked why she was still wearing a gown, Resident #37 replied, I don't know. The resident further stated that she would like to be wearing her personal clothing, but nobody helped her to get dressed. On 02/13/24 at 4:31 PM, Resident #37 was observed in bed. When asked about not participating in Bingo earlier in the day, Resident #37 replied, I don't know, I would like to go play Bingo. I've been in my bed all day. I want to get out of bed every day. 2.) During an observation of lunch, on 02/11/24 at approximately 12:00 PM, it was noted that there were no residents eating the meal in the dining room. During the observation, which continued to the Hibiscus unit (Rooms #100 to 128) and the Dolphin unit (Rooms #200 to 222), Resident #56 was noted to still be in bed and served lunch in the room. On 02/11/24 at 12:22 PM, the Administrator reported to a survey team member that it was Resident Council's decision to not eat lunch in the dining room on the weekends. During an observation of lunch being served to the residents in their rooms on the Hibiscus and Dolphin units, on 02/12/24 at approximately 12:00 PM, Resident #56 was noted to be served in her room while still in bed. During a meeting with members of the Resident Council, on 02/12/24 at 2:30 PM, including Resident #22 with a Brief Interview for Mental Status (BIMS) score of 15, Resident #56 with a BIMS of 15, and a resident that wished to remain anonymous with a BIMS score of 15, when asked about having meals in the Dining Room, Resident #56 stated, We don't eat lunch in the dining room on the weekends, because there is not enough staff. I have asked the head cook and he said that there are not enough staff or enough people for us to eat in the dining room (referring to there not being enough staff to assist residents to the dining room). Resident #22 and the resident that wished to remain anonymous also stated that they preferred to eat in the dining room. During an interview, on 02/14/24 at 12:38 PM, with Staff Q, CNA, when asked about residents having meals in the dining room, Staff Q replied, some want the dining room and some don't. When asked about Resident #56 being in bed during lunch, Staff Q replied, I don't know, she is always in the dining room. During an interview, on 02/14/24 at 1:21 PM with the Food Service Director (FSD), when asked about residents wanting to eat meals in the dining room, the FSD replied, it is an ongoing battle. A lot are not even getting offered to go to the dining room. 3) Resident #38 was initially admitted to the facility on [DATE] with diagnoses that included Respiratory failure, Hemiplegia, and Diffuse Traumatic brain trauma. A review of the resident's Brief Interview for Mental Status (BIMS) score revealed he scored a 10 on the quarterly Minimum Data Set (MDS) dated [DATE]. This revealed the resident had mild cognitive impairment. The MDS also revealed the resident was totally dependent with showering and bathing. The resident's care plan revealed he was totally dependent on 1-2 staff to provide bathing/showering, bed mobility, transfers and requires a Hoyer lift with 2 staff assistance for transfers. On 02/12/24 at 10:00 AM, an interview was conducted with Resident #38 regarding his activities of daily living. The resident stated that he would like to have more showers since he has been getting showers every 2 weeks and not three times a week as he wanted. Resident #38 stated that he needs a 105372 Page 3 of 51 105372 02/14/2024 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0561 Hoyer lift for the shower. Level of Harm - Minimal harm or potential for actual harm This surveyor then spoke with the resident's mother via telephone on 02/12/24 at 10:18 AM and she stated she wished he could have more showers as he was scheduled for. Residents Affected - Few On 02/12/24 at 10:08 AM, an interview was conducted with Staff I, a certified nursing assistant (CNA). Staff I stated she had been working at this facility for 11 months and she would be giving Resident #38 his shower today. This surveyor asked Staff I where she documents what type of bath the resident receives and she stated she does not document in the Electronic Health Record (EHR) since she doesn't have a password. She was asked for documentation of what type of bath/shower she gives Resident #38. She pulled out a book of paper documentation but there was no documentation for Resident #38. An additional interview was conducted with Staff I on 02/12/24 at 3:20 PM. She stated she gave Resident #38 a bed/sponge bath today because there weren't enough pads for the Hoyer lift. An interview was conducted with Staff O, a licensed practical nurse (LPN) who was standing next to Staff I at the time of the interview. Staff O stated all of the CNAs document in the task section of the EHR and that is why there is no paper documentation for showers. An interview was conducted with the Director of Housekeeping on 02/12/24 at 3:30 PM regarding the availability of pads that are used for Hoyer lift for showers. He stated that he has 4-5 pads available for an extra large person and some more in storage so there should never be an issue to obtain a pad. An interview was conducted with the MDS Coordinator on 02/12/24 at 4:03 PM who has worked in this facility for 2 years. She was asked to provide the CNA shower documentation for Resident #38. There were no showers marked for the last 30 days. 105372 Page 4 of 51 105372 02/14/2024 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify representative for change of condition for 1 of 4 residents sampled for hospitalizations (Resident #9) and 1 of 3 residents reviewed for falls (Resident #12). The findings included: 1. Resident #9 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident was moderately cognitively intact. A progress note dated 01/17/24 at 1:13 PM documented the resident was confused and not oriented. The physician/nurse practitioner was called and was in the facility to assess the resident. An order was received to transfer Resident #9 to the hospital for altered mental status for evaluation. Resident #9 was transferred from the facility at 2:50 PM. Further record review did not reveal the resident's representative was notified of the resident's change in condition. 2. Resident #12 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident was mildly cognitively intact. Record review revealed the resident had a fall on 01/27/24. Further review of Resident #12's record did not reveal the resident's representative was notified of the resident's fall. An interview was conducted with Resident #12's representative on 02/14/24 at 12:00 PM. The representative stated she was not aware the resident had a fall. No one contacted her. 105372 Page 5 of 51 105372 02/14/2024 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) On 02/13/24 at 11:32 AM wound care was observed for Resident #20 with Staff K, a licensed practical nurse (LPN), who is designated as the wound care nurse. Staff K stated she had been working in the facility for 2-3 years and for the last 1.5 years as a wound care nurse. Residents Affected - Few The room where Resident #20 resided contained 4 beds. Two residents were in the room at the time of the wound care observation, Resident #38, and the resident in the bed next to him. The privacy curtain was between them, however, at the start of wound care the privacy curtain was not pulled. The resident in the adjacent bed could see what was being done to Resident #20. Staff K was observed washing her hands, donning gloves, removing the old dressing, doffing her gloves, washing her hands then donning gloves to prepare to apply a new dressing to the wound. At this time, Staff K pulled the privacy curtain closed so the adjacent resident could not visualize Resident #20. After wound care was completed, discussed with Staff K the privacy curtain should be pulled prior to the commencement of wound care. Based on observations, interviews, and record review the facility failed to close privacy curtain during wound care for 1 of 2 residents sampled for wound care (Resident #20); and failed to provide privacy during medication administration for 1 of 4 residents observed for medication administration (Resident #4). The findings included: Review of the facility policy titled Resident Rights- Exercise of Rights with a revised date of 03/02/19 included the following: The facility will treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Each resident will be treated with dignity and respect. 1) Record review for Resident #4 revealed the resident was admitted to the facility on [DATE] with a diagnoses that included: Anoxic Brain Damage, Tracheostomy Status, Other Involuntary Movements, and Unspecified Voice and Resonance. Review of the Minimum Data Set (MDS) for Resident #4 dated 01/18/24 revealed in Section C a Brief Interview of Mental Status score of 15, indicating a cognitive response. During the medication administration observation on 02/11/24 from 9:48 AM to10:30 AM for Resident #4, Staff C, Registered Nurse (RN), did not provide privacy for the resident. Staff C left the resident's door wide open and did not pull the privacy curtain during the medication administration, leaving the resident in full view of any resident, visitor or staff passing by the resident's room. During an interview conducted on 02/11/24 at 10:35 AM with Staff C she stated she knew she made some mistakes (during the medication administration). When asked about providing privacy for Resident #4 during the medication administration, she said she should have provided privacy for the resident. Staff C acknowledged she did not close the resident's door or pull the privacy curtain for the 105372 Page 6 of 51 105372 02/14/2024 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0583 resident (during medication administration). Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 105372 Page 7 of 51 105372 02/14/2024 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to provide maintenance and housekeeping services to maintain a clean, sanitary and home like environment for 17 of 29 rooms on the Hibiscus unit (Rooms #100 to 128), 6 of 17 rooms on the Dolphin Unit (Rooms #200 to 222), 3 of 3 unit corridors and the common areas that included the Activities/Dining area, lobby/reception area, the laundry, and corridors leading to the units from the lobby/reception area. The findings included: 1). During the Environment Tour conducted on the Hibiscus Unit (rooms 100 to 128), on 02/13/24 at 2:15 PM, accompanied with the Director of Maintenance, the following were noted: room [ROOM NUMBER]: The floor area surrounding the room entry door and throughout the room were noted to be black stained and heavily soiled with dust, dirt, and debris. Small hole (2 diameter) in wall above Bed-A. room [ROOM NUMBER]: The exterior of the room entry door was in disrepair. Room floor and base boards were soiled and stained throughout. room [ROOM NUMBER]: The exterior bases of the two IV poles being utilized for gastric tube feeding pumps for A & B beds were noted to be corroded and rust laden. The privacy curtain was soiled with dried brown matter (Bed-A). Room # 103: The exterior of the room chair handles and legs were heavily worn. room [ROOM NUMBER]: The exterior of the room chair was heavily worn, room base boards were heavily soiled and large areas of black scuff marks, room floor soiled and stained black throughout the room, and the bathroom call bell cord was wrapper twice around the wall handrail and was inoperable when being pulled for testing. room [ROOM NUMBER]: Room floor was heavily soiled and large black stains throughout, and room baseboards were soiled and stained with black scuff marks. room [ROOM NUMBER]: Room floor was heavily soiled and large black stains throughout, and room baseboards were in disrepair and require repainting . room [ROOM NUMBER]: Room floor was heavily soiled and large black stains throughout, and room baseboards were in disrepair and require repainting. room [ROOM NUMBER]: Bathroom call bell was wrapped repeatedly and was tied around the wall handrail and could not be operational when tested. room [ROOM NUMBER]: Room floor was heavily soiled and large black stains throughout, and room baseboards were in disrepair and require repainting. 105372 Page 8 of 51 105372 02/14/2024 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some room [ROOM NUMBER]: The walls (4) of the bathroom were noted to be covered with a black mold type substance. room [ROOM NUMBER]: The room floor had a large line (12 feet) of black stain, room floors and base boards were heavily soiled and stained, and exterior of the overbed table (1) was in disrepair and rust laden. room [ROOM NUMBER]: The exterior of the room entry door had large black scuff marks, privacy curtain (Bed-A) was noted to have areas of dried brown matter, bathroom noted to have pervasive urine odor, and 1 of 3 bathroom wall lights were not working. room [ROOM NUMBER]: The room closet door for (Bed-W) was missing. room [ROOM NUMBER]: Room floor was heavily soiled and large black stains throughout, and room baseboards were in disrepair and require repainting. room [ROOM NUMBER]: Resident reporting the television remote control has not been working for approximately 3 days. Resident stated she was afraid to report the issues. room [ROOM NUMBER]: Room floor was heavily soiled and large black stains throughout, and room baseboards were in disrepair and require repainting, and bathroom call light cord was wrapped around the wall handrail several times. Hallway: The ceiling tiles (4) and ceiling vent located outside of the nurses station were soiled, stained, and areas of black mold type matter. Hallway: The ceiling tiles (4) and ceiling vent located outside of resident room [ROOM NUMBER] were soiled, stained, and areas of black mold type matter. Following the 02/13/24 tour, the findings were discussed with the facility Administrator. 2). During the observation tour of the facility's main laundry area on 02/12/24 at 1 PM, and accompanied with the facility's Director of Maintenance, the following were noted: (a)The walls of the soiled/sorting room were noted to have 2 large holes (approximately 3X5). (b) The wash room was noted to have the following: < Large areas of the room ceiling and ceiling tiles (5) were noted to be heavily soiled and falling down from the ceiling tracks. < The room walls (2) were soiled and in disrepair (numerous holes). < The exterior of the ceiling air-conditioning vents (2) were dust laden and layered with black mold type matter. < The wall area and exhaust vents located behind the washing machine (4) were noted to have a thick layer of black mold type matter. 105372 Page 9 of 51 105372 02/14/2024 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0584 < One of two ceiling mounted lights were not operational. Level of Harm - Minimal harm or potential for actual harm < The exterior of the wall mounted commercial fan was noted to be dust laden. The fan was noted to be blowing directly onto the front of the washing machine area. Residents Affected - Some < Only 3 of the 4 commercial washing machines were operational. The Maintenance Director stated that the one washing machine has been out of operation for approximately one year. Further stated that there was no time frame for repair. < The drainage trough (8 feet) located behind the commercial washing machines (4) was noted to have a heavy builld-up of sludge, discarded gloves, and masks. c) The Dryer/Clean Linen Folding room was noted to have the following: < Only three of the four commercial dryers were operational. The Maintenance Director stated that the 1 commercial dryer has been out of operation for a few months. Further stated there was no time frame for repair. < The exterior of the ceiling mounted air-conditioning vent located in the middle of the room was noted to have a thick layer of dust. < The lint trap screens of the 3 operational commercial dryers were noted to be covered with a thick layer of lint. Numerous balls of lint were also noted to be coated in the lint catch area of all three dryers. The surveyor stated to the Director that the lint trap screens appeared not to be cleaned on a regular basis. The Director stated that the lint trap screens are required to be cleaned every 2 hours and to be documented on the Laundry Dryer Log. A review of the Laundry Dryer Log for February 2024 noted no documentation of cleaning every 2 hours from February 1-10, 2024. Further review noted that on 02/12/24 the last 2 hour cleaning was documented at 11 AM. The Director stated that the cleaning of the lint trap screens was not being conducted and documented every 2 hours. It was also discussed with the Director that there was the potential for a dryer fire due to heavy collection of lint. * Review of the facility's Policy & Procedure for the cleaning of the Lint Catch/Screens (no date) noted the following procedure: < Lint Catchers should be cleaned after each load. 3). a. In room [ROOM NUMBER], the surface of the nightstand was worn in a manner that the particle board underneath was exposed and the quarter round molding at the floor and baseboard juncture was worn in a manner that the raw wood underneath was exposed. b. In room [ROOM NUMBER], the closet did not have a door. c. In room [ROOM NUMBER], the floor around the toilet in the shared restroom was not sealed properly, the floor around the toilet was damaged and there was no hot water at the bathroom hand sink. d. In room [ROOM NUMBER], there was no privacy curtain between the A and B beds, the ceiling was not finished where repairs had been made. 105372 Page 10 of 51 105372 02/14/2024 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0584 e. In room [ROOM NUMBER], 1 of the 3 bulbs in the shared restroom had burned out and the fall mat at the window bed was torn. Level of Harm - Minimal harm or potential for actual harm 4). On the Dolphin unit, Rooms 200 to 222, the following were noted: Residents Affected - Some a. The floor at the Dolphin Unit nurse's station was damaged in a manner that could pose a tripping hazard. b. there were several ceiling tiles that were stained in a manner indicative of the tiles being wet around the air conditioning vents and air intake. 5). The handrail outside of room [ROOM NUMBER] had separated in a manner that residents with fragile skin are at risk for obtaining skin tears when used to assist in ambulation. 6). Throughout the facility, including the unit corridors and the common areas, the quarter round at the floor and base board juncture was damaged and the paint was peeling. Following the tours of the Dolphin Unit, the Hibiscus Unit and the common areas, on 02/14/24 at 1:23 PM, with the Director of Maintenance and Housekeeping, they acknowledged the concerns. 105372 Page 11 of 51 105372 02/14/2024 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that 1 (Resident #79) of 10 sampled residents for nutrition review failed to be given the appropriate treatment of supervision and adaptive eating equipment with meals to maintain or improve ability to eat independently. Residents Affected - Few The findings included: During the observation of the lunch meal conducted on 02/11/24 at 12:15 PM, it was noted that the lunch tray was placed in front of resident and staff left room. It was noted that the tray foods were served in bowls and only 1 built-up spoon and regular spoon, fork, and knife were provided on the tray. The resident was noted to have visual impairment and some cognitive impairment. The resident was noted to attempt to eat the foods with the regular spoon but ate with the spoon upside down. The resident was noted to utilize the built -up spoon only for a few attempts with the foods in bowls. Staff were noted not to assist or supervise Resident #79 during the meal, and the resident consumed less than 20 % of the lunch meal. Observation of breakfast meal on 02/13/24 at 8:20 AM noted Mechanical Soft /No Added Salt diet tray served to room. Resident alert with some confusion. All foods served in bowls that included toast, eggs, ground sausage, and cold cereal. A review of the resident's meal tray ticket documented: Grip Spoon (noted only 1 spoon provided, with regular fork , spoon, and knife). Further observation noted resident using regular spoon flipped backwards and attempting to eat . Resident received no assistance from staff during the meal observation. The Occupational Therapist (OT) was noted to be in the resident's room at 8:40 AM and was interviewed by the surveyor. The OT stated to the surveyor that the resident was picked up for therapy a few weeks ago by skilled therapy for eating ability. Further stated that facility staff are not providing the supervision/assistance with meals and not receiving the proper built-up utensils (spoon, knife, fork) to improve the resident's eating ability. Stated the meal tray ticket should be documented all spoon, knife, and fork to be built-up, and that the facility does not have a Restorative Nursing Dining Program and that the resident is legally blind and requires set up and assistance. The meal tray was taken away from the resident and approximately only 20 % of the meal was consumed. ***During the observation of the lunch meal on 02/13/24 at 12:45 PM it was noted that the meal tray was served to the room of Resident #79. Resident noted to be alert with some cognitive impairment and visual impairment. Review of the resident's meal tray ticket documented food to be served in 3 bowls and built-up spoon. Only 2 bowls of foods were served that included only the entrée and vegetable and 1 built-up spoon was provided. The tray should have contained an extra serving of Garlic bread and bowl of cookies, and also 4 ounces of cranberry juice and 8 ounces of water. Resident meal tray was set up by the CNA , however the resident could not eat independently without supervision and assistance. The aide was noted to only spend minimal time with the resident and resident noted to consume less than 50% of the meal tray foods. On 02/13/24 at 1:15 PM the facility's Diet Technician submitted to the surveyor a new meal tray ticket. Review of the meal ticket documented the addition of Grip Fork (1), Grip Knife (1), and Grip Spoon (1) with all meals, and all foods in individual bowls. A review of the clinical record of Resident #79 noted the following: 105372 Page 12 of 51 105372 02/14/2024 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0676 Date Of admission: [DATE] Level of Harm - Minimal harm or potential for actual harm re-admission: [DATE] Diagnoses: Encephalopathy/ COPD/Legal Blindness / Psychosis/Dementia/ Anxiety/ ASHD/Hearing Loss Residents Affected - Few Current MDS: 11/12/23 - Quarterly Section B : Adequate Vision - Usually understood and Understands Section C : BIMS =5 (some cognitive impairment) Section D: No Mood Issues Sec GG : Eat - Set-up Assistance Sec K : No Swallow Disorder/Height=71/Weight=128#-with Unknown Wt Loss Mechanically Altered Diet /Therapeutic Diet Weight History: 2/6 = 120 # (8 pound weight loss) 1/4 = 128 # 1/6/=128 # 10/5 = 128 # BMI = 16.6 (underweight) Ht= 71 IBWR = 160 - 210 pounds Progress Note Review: Record noted no record of DTR/RD Progress Notes or Quarterly Progress Notes. Review of Nutritional assessment dated [DATE] noted: Weight: 120# Height: =71 Usual Body Weight= 128# since admission Diet = No Added Salt/Mechanical Soft Diet 105372 Page 13 of 51 105372 02/14/2024 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0676 Intake = 51-100% Level of Harm - Minimal harm or potential for actual harm Feed: Independent Nutritional Risk : Weight Loss, Risk For Pressure Sores, Legally Blind Residents Affected - Few Summary: Impaired Cognition, unable to review food preferences/ BMI 16.6 = underweight /significant weight loss of 6.2% in 30 days Able to fed self with set up and supervision- needs assist due to legal blindness, Risk for Impaired nutritional status recent weight loss, dementia, current intake insufficient to meet needs. Add Med Pass 2.0 120 ml BID for nutritional support = 480 cal/10 gm Protein. Current Physician Orders: 2/13/24: Adaptive Equip: individual bowls for all meal items (new since interview with OT) 2/13/24: Adaptive eating equipment - must use red foam padded utensils for all meals (new since interview with OT) 02/06/24: Large protein for lunch 2/6/24 -= No Added Salt/Mechanical Soft Meat- bite sized pieces 02/08/24: = Caloric dense Oral Supplement - Med Pass 2.0 = 120 ml BID. 2/4 - Crush medication in applesauce pudding 2/8 -Seroquel 50 mg Q HS Psychosis Current Care Plan 2/12/24 noted: * Nutritional Problem - The approaches did not doumentent the following: < food in bowls < Built-up utensils < Med Pass 120 ml BID (supplement) * ADL Self Care : < Red padded Utensils for all meals ( Only 1 built-up spoon provided with meals) < Plate Guard ( Should documented all food in bowls) 105372 Page 14 of 51 105372 02/14/2024 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0676 < Eating - set up and supervised assist with meals (not noted during observations) Level of Harm - Minimal harm or potential for actual harm * Impaired Visual Function <Tell resident where you are placing food items items Residents Affected - Few <The resident uses glasses (no glasess were noted to be worn by the resdient during observations) 105372 Page 15 of 51 105372 02/14/2024 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

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 observation, interview, and record review, it was determined that the facility failed to provide 1 (Resident #19) of 10 sampled residents who are unable to carry out activities receives the necessary services to maintain good nutrition. Residents Affected - Few The findings included: During resident screenings conducted on 02/11/24 at 10 AM it was noted that Resident #19 appeared underweight/malnourished and was cognitively impaired. Observation conducted on 02/13/24 at 8:30 AM noted regular meal tray served to the room of Resident #19. Staff was noted to only set up the tray in front of the resident and then staff left room. Resident noted to be cognitively impaired and could not eat independently and required supervision and assistance with eating. During the 30 minute observation no staff were noted to enter the room and provide assistance with Resident #19. Resident was noted to consume 0% of the breakfast meal. At 8:45 AM the resident was noted to be sleeping in front of the meal tray and staff were noted to remove the food tray from room. During an observation conducted on 02/13/24 at 3 PM, it was noted that the resident was seated in a chair in the room with the lunch tray located on the over-bed table. Further observation noted that 0% of the lunch foods were eaten and there were no staff noted to coming in/out of the room. The tray foods appeared to be dried out from sitting out uncovered for a long period of time (2 plus hours). Observation of Resident #19 on 02/14/24 at 8:30 AM noted resident sitting in chair with breakfast tray on over-bed table. Resident noted to not be awake and alert. No supervision or assistance noted by staff. Noted to consume less than 20 % of the breakfast meal. Review of the clinical record of Resident #19 on 02/12/24 noted the following: Date Of admission: [DATE] - Hospice Medicaid Diagnoses: Cerebral Arteriosclerosis, Anxiety Disorder, Dementia with Behavioral Disturbance. Current physician orders noted the following: 2/12/24 - Admit to Vitas Hospice 11/11/23 - Regular Diet/Thin Liquids * Noted no physician orders for high calorie/protein supplements. Review of Weight History: 2/7/24 = 108# 1/4/24 = 110# 105372 Page 16 of 51 105372 02/14/2024 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0677 BMI : 21.1 Level of Harm - Minimal harm or potential for actual harm Height: 60 Ideal Body Weight Range: 113-149 # Residents Affected - Few review of current MDS : 11/17/23 - admission Section B : Sometimes Understands Sec C: BIMS Score= 3 (Cognitive Impairment) Sec D : No Moods Sec GG: Eating - Requires Supervision and Touching Assistance Sec K : NO Swallowing Dis , 60/110#, Sec L ; No dental issues Review of Nutrition Assessments/Risk Screen: Date: 11/27/23 Weight: 110# Ht = 60 Usual Body Weight: Unknown BMI= 21.5 Diet = regular Meal Intake =25-100% Ability to feed self - yes Skin : NO issues Risk Factors:/Inadequate meal intake/Advanced Age Needs: cal =993-1191/Pro = 50-60 gm /fluids: 1500 -1750 Summary: BMI underweight for age [AGE]-26 ideal, Hospice Care average intake 50%, no Labs , Review of current Care Plan noted 105372 Page 17 of 51 105372 02/14/2024 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0677 * Nutritional Problem : Level of Harm - Minimal harm or potential for actual harm Maintain adequate nutritional status /maintain weight * Invite to activities to promote additional intake - (no activities noted for resident from 02/11-14/24) Residents Affected - Few * Observe significant wt loss - (no documentation of weight loss issues) * Obtain labs - No labs ordered * Supplementation (no oral protein/calorie supplements ordered) * Self Care: * Eating - requires supervision to set up, assistance by staff to eat (meal observations from 02/11-14/24 noted no assistance by staff during meals) 105372 Page 18 of 51 105372 02/14/2024 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0679 Provide activities to meet all resident's needs. 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 provide ongoing activities program for 4 of 4 residents, Residents #56, 22, 37, and a resident that wishes to remain anonymous. Residents Affected - Few The findings included: The Admissions packet documented, the Activity Department at Avante offers a variety in both group and individual programs designed to meet the needs and interests of our residents. Participation is encouraged but not mandatory. We encourage our residents to continue to do things they have enjoyed in the past, as well as trying new opportunities. Suggestions for programs are welcome and your involvement is encouraged. Programs such as arts and crafts, physical activities, religious programs, bingo, discussion groups, and current events are offered on a daily, weekly, or monthly basis. The facility's policy, 'Activities Meet Interest/Needs of Each Resident', with an issue date of 03/02/19 documented, The facility will provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community. A review of the Activities Calendar for the month of February 2024 revealed the following: Each Sunday, the only activity is Bible Study at 2:45 PM Each Thursday, the only activities are 'Biggest Loser' at 1:15 PM and Bingo at 2:30 PM. Each Saturday the only activities are Morning News and word search puzzles that are kept at the nurse's stations on the units and are individual activities done by the residents in their rooms. 1). During an interview, on 02/11/24 at 1:37 PM, with the Activities Director, when asked about the activities, the Activities Director stated that Resident #49 leads the 'Bible Study' on Sundays. The Activities Director described the 'Biggest Loser' activity was for residents that had successfully lost weight. The Activities Director stated that the 'Morning News' was just turning the TV on in the residents' rooms. When this surveyor requested a schedule for activities staff, the Activities Director replied, I am the only one, I don't have a staff. There is no money in the budget for additional staff. 2). On 02/11/24 at 1:46 PM, 8 residents were noted to be in the lobby/reception area by the reception desk. When asked why the residents were in the area, Staff R, Receptionist replied, I don't know, they were here when I got back from lunch. During the observation and interview, it was noted that there were no other staff tending to or interacting with the residents. During an interview with Resident #95, a resident with a Brief Interview for Mental Status (BIMS) score of 10, when asked about the observation, Resident #95 replied, it's something to do. 3). Resident #56 was initially admitted to the facility on [DATE], According to a quarterly MDS, dated [DATE], Resident #56 had a BIMS score of 15, indicating the resident was 'cognitively intact'. 105372 Page 19 of 51 105372 02/14/2024 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The MDS documented that the resident was dependent upon staff for ADLs except for eating. Resident 56's diagnoses at the time of the assessment included: Hemiplegia, Seizure disorder, Anxiety disorder, Depression, Epilepsy. Resident #56's care plan for Activities, initiated on 10/06/20, with a revision date of 05/07/21, documented, Resident has a current interest in Recreational activities of choice such as arts & crafts, listening to music, 1:1 visits with Activity therapist, Talking on Phone with daughter, Birthday socials, Movies, Socializing with other residents, Watching television, relaxing in the front lobby with the receptionist. The goals of the care plan included: *Resident will maintain involvement in cognitive stimulation, social activities as desired through review date. *Will not experience any adverse effects throughout the review period 10/06/20 with a revision date of 12/14/23 and a target date of 04/13/24. Interventions to the care plan included: *Establish and record the resident's prior level of activity involvement and interests by talking with the resident, caregivers, and family on admission and as necessary. *Honor residents desire to decline invitation to group activities, providing 1:1 bedside. * In-room activities & visits as needed if unable to attend out of room events due to COVID-19 Procedures. *Lifestyles & Activities - Encourage & Redirect to engage in Therapeutic Activities of choice and enhance the resident's leisure quality of life. *Provide activities which do not involve overly demanding cognitive tasks. Engage in simple, structured activities such as listening to music, reading magazines, Audio books, coloring, coloring books. *Provide items and materials as available to fully engage in preferred self-directed independent activity pursuits as needed. *Provide with monthly activities calendar. Notify resident of any changes to the calendar and offer assistance to & from activities of choice as needed/tolerated. Resident #56's care plan for nutrition, initiated on 01/19/22, documented The resident has a nutritional problem. The goal of the care plan was documented as, the resident will not develop complications related to obesity . 01/19/22 with a revision date of 12/14/23 and target date of 04/13/24. Interventions included: 105372 Page 20 of 51 105372 02/14/2024 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0679 Level of Harm - Minimal harm or potential for actual harm *Develop an activity program that includes exercise, mobility. Offer activities of choice to help divert attention from food. On 02/11/24 at 1:27 PM Resident #56 was observed in bed. The resident called this surveyor into the room and stated that she had not been out of bed. Residents Affected - Few During a follow up interview with Resident #56, on 02/12/24 at 11:02 AM, Resident #56 stated that she was not assisted out of bed the previous day until approximately 2:00 PM. Resident stated usually they don't get me out of bed at all (referring to being out of bed on the weekends). During an interview, on 02/12/24 at 2:30 PM, with members of the Resident Council, including Resident #56, when asked about participating in scheduled activities during this day, Resident #56 replied, they didn't even get me out of bed until it was time for this meeting. The resident stated that she missed out on the 'Hot Chocolate' activity and that she would have participated had she been out of bed. 3). During a meeting with members of the Resident Council, on 02/12/24 at 2:20 PM, including Resident #22, with a BIMS of 15, Resident #56, and a resident who wished to remain anonymous, with a BIMs of 15, when asked about activities, the resident who wished to remain anonymous replied, we don't even have a budget for activities. The Activities director said that there is no budget as well. We have a hard time getting people to come to activities. We used to have a lot of people in the dining room when the former FSD was here. Residents #22 and #56 voiced agreements with the statement made by the resident who wished to remain anonymous. 4). Resident #37 was initially admitted to the facility on [DATE]. According to the 5-day Minimum Data Set (MDS), dated [DATE], Resident #37 had a Brief Interview for Mental Status (BIMS) score of 14, indicating that the resident was 'cognitively intact'. The MDS documented that Resident #37 was dependent upon staff for Activities of Daily Living (ADLs) except for eating and oral hygiene. Resident #37's diagnoses at the time of the assessment included: Respiratory failure with hypoxia or hypercapnia, Hemiplegia, Seizure disorder, Malnutrition, Adjustment disorder with depressed mood, Functional Quadriplegia, Tracheostomy status, Gastrostomy status, Cerebral infarction, Hemiplegia following cerebral infarction affecting left nondominant side. Resident #37's care plan for activities, initiated on 01/11/24, documented, the resident is independent for meeting emotional, intellectual, physical and social needs noted by the Activities Director. The goal of the care plan was documented as, The resident will maintain involvement in cognitive stimulation social activities as desired through review with a target date of 03/20/24. Interventions to the care plan included: *All staff to converse with resident while providing care. *Encourage ongoing family involvement Invite the resident's family to attend special events, activities, meals. On 02/12/24 at 12:12 PM, Resident #37 was observed in her wheelchair wearing a hospital gown. When asked why she was still wearing a gown, Resident #37 replied, I don't know. 105372 Page 21 of 51 105372 02/14/2024 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0679 Level of Harm - Minimal harm or potential for actual harm On 02/13/24 at 4:31 PM, Resident #37 was observed in bed. When asked about not participating in Bingo earlier in the day, Resident #37 replied, I don't know, I would like to go play Bingo. I've been in my bed all day. I want to get out of bed every day. When asked about attending the 'Fat Tuesday Trivia' (Mardi Gras celebration), Resident #37 became upset about missing the activity. When asked why she did not attend, Resident #37 replied, I don't know, they didn't get me out of bed. Residents Affected - Few 105372 Page 22 of 51 105372 02/14/2024 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to provide treatment and care in accordance with professional standards of practice to ensure that 1 (Resident #31) of 2 sampled residents for dialysis review with meals prior to leaving for dialysis appointments and bagged lunches to take to dialysis treatment appointments; failed to provide 1 (Resident #98) of 2 sampled residents with physician ordered pain medication; and failed to provide a consult for 1 (Resident #48) of 2 residents reviewed for physician ordered dermatology consults. Residents Affected - Few The findings included: 1) During the screening and interview conducted with Resident #31 on 02/12/24 at 8:15 AM, it was noted that she was located in the hallway and stated to the surveyor that the dialysis transport will be at the facility soon to take her to dialysis. Resident #31 further stated that she would be leaving for dialysis transport at 8:30 AM and had not eaten the breakfast meal and she would like to eat her breakfast meal prior to leaving for dialysis. Further interview stated that she rarely is served breakfast meals before dialysis transport on Monday, Wednesday, and Friday and has asked staff repeatedly to have an early breakfast on dialysis days. During the 02/11/24 interview the resident also stated that she is not given a bagged snack/lunch on dialysis day and is very hungry with nothing to eat while at the dialysis treatment center, and states she has had weight loss. It was also noted during the interview with Resident #31 on 02/12/24 at 8:30 AM that the dialysis transport drivers came to pick up Resident #31 and she stated she was not ready to go until she could eat a breakfast meal . The drivers left the facility without taking the resident out of the facility to dialysis appointment . At the end of the 02/12/24 interview the surveyor requested the Corporate Food Service Director to see Resident #31 to set an early breakfast meal tray on dialysis days and to take a bagged lunch with her to dialysis. On 02/14/24 at 8:30 AM, it was noted that the resident was leaving with dialysis transport with a bagged lunch, and the resident also stated that she received an early breakfast tray and thanked the surveyor for his efforts. The resident repeated numerous attempts to get facility staff to provide early breakfast tray and bagged lunch. Clinical record review of Resident #31 noted physician order dated 02/13/24 for an early breakfast tray and bagged lunch on dialysis days. Further clinical record review noted the following: Date Of admission : 9/26/23 Re- admission: [DATE] Diagnoses: ESRD, Fluid Overload, Anxiety, Cirrhosis, and Diabetes Type 2. Current Physician Orders: 01/25/23 - Regular Diet 1/25/24 - Novasource BID 85 ML/Hour X 12 hours on at 8 PM and off at 8 AM via G tube. Flush 2 times water 75 ml X 12 on 2 PM off 8 AM. 105372 Page 23 of 51 105372 02/14/2024 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0684 Weight History: Level of Harm - Minimal harm or potential for actual harm 2/7 = 157 2/5=162 Residents Affected - Few Height = 67 inches BMI=24.6 Ideal Body Weight Range = 140-185 pounds Current MDS: 12/16/23 Sec C: BIMS =14 (NO Cognitive Impairment Sec D: Depressed Sec GG: Eats Independently 2) On 02/12/24 at 9:38 AM, an observation of Resident #48's left foot and leg was done. The areas were red and the resident was observed scratching the areas. The resident was mostly Spanish speaking and was unable to tell this surveyor if he had seen a physician about this rash. Record review revealed Resident #48 was initially admitted to the facility on [DATE] with diagnoses of Hemiplegia, Hypertension and Peripheral vascular disease. A review of Physician's orders revealed Triamcinolone Acetonide External Cream 0.5% was ordered on 01/07/24 for rash bilateral lower legs for 14 days. This ended on 01/21/24. Nystatin-Triamcinolone External Ointment was ordered on 01/26/24 for bilateral lower leg pain which ended on 02/09/24. On 02/01/24 Staff M, a Nurse Practitioner, wrote a progress note regarding the rash on Resident # 48's lower legs. In the note, Staff M stated he would refer the resident to a dermatologist. On 02/08/24 in another progress note written by Staff M, he again referred to Resident #48 seeing a dermatologist. On 02/12/24 at 4:00 PM, an interview was conducted with Staff L, the staffing coordinator. Staff L was asked if there was a dermatology appointment scheduled for Resident #48 or was there an appointment that was not reflected in the medical record. Staff L stated there was no appointment scheduled and the resident did not have an appointment. An interview was conducted with Staff M, Nurse Practitioner, on 02/13/24 at 3:44 PM. Staff M stated he did want Resident #48 to see a dermatologist. He said he gave a verbal order. He was not aware that the resident had not yet seen a dermatologist and still had the rash. 3) On 02/11/24, an observation was made of Resident #98 in his bed. His call light was observed on the floor next to his bed with the clip attached to a cap (photographic evidence obtained). The resident was unable to answer questions except for a head shake therefore interviews and record 105372 Page 24 of 51 105372 02/14/2024 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0684 review were done to understand the resident's condition. Level of Harm - Minimal harm or potential for actual harm Resident #98 was initially admitted to the facility on [DATE] with diagnoses that included Traumatic subarachnoid hemorrhage, Pain in right shoulder, and Seizures. Residents Affected - Few Section C of the 5-day Minimum Data Set (MDS) with an assessment reference date of 01/09/24 revealed a Brief Interview of Mental Status (BIMS) score of 7 which indicated severe cognitive impairment. Section GG of the same MDS revealed he was dependent with transfers, sitting to lying in bed and toileting. This meant the resident was highly dependent on his call light being next to him. On 12/15/23 the physician prescribed Meloxicam tablet 7.5 mg (milligrams) give 1 tablet for pain every 8 hours for pain for 21 days. Also prescribed was Percocet 5-325mg give 1 tablet by mouth three times a day for pain for 30 days. A review of the Medication Administration Record (MAR) revealed the resident did not have Meloxicam on 02/15/23, 2/18/23, 2/19/23, 12/20/23, 12/21/23, 12/22/23, 12/23/23, 12/24/23, 12/25/23 and 12/26/23. The resident did not get all doses of Percocet on 12/15/23, 12/16/23, and 12/18/23. On 12/15/23 the nurse documented in the progress note that she was awaiting the pharmacy and did not give Percocet and Meloxicam. On 12/16/23 the nurse documented in the progress note that she was awaiting Meloxicam and Percocet-it was on back order. On 12/17/23 at 10:00 PM the nurse documented no reason why the Meloxicam was not given. On 12/17/23 at 6:36 AM the nurse documented the Meloxicam was on backorder. On 12/18/23 at 8:24 AM the nurse documented the Percocet was not given because the resident denied pain but marked the pain level at 9 in the MAR. On 12/18/23 at 7:30 PM the resident was sent to the hospital post fall and returned to the facility on [DATE] at 4:40 PM. On 02/13/24, an interview was conducted with the Director of Nurses (DON). The DON was asked about the delay in receiving Meloxicam and Percocet from the pharmacy for Resident #98. The DON was not able to explain why the medications were delayed. On 02/14/24 at 9:06 AM, an interview was conducted with the Regional Director of Clinical Services regarding the delay in receiving medications for Resident #98. She stated that when a medication is ordered the expected time for delivery is 4 hours for a stat dose and it comes on the next run. If not ordered stat, the medication would be available from the pharmacy the next day. One delivery comes morning and one comes 4:00-5:00 PM. She stated Percocet 5-325mg is in the Omnicell for stat use but Meloxicam is not and could not explain why the nurse did not obtain the Percocet from the Omnicell. 105372 Page 25 of 51 105372 02/14/2024 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0684 Level of Harm - Minimal harm or potential for actual harm A phone interview was conducted with the consultant pharmacist (Staff J) on 02/14/24 at 9:52 AM. She stated if the order is faxed late, the medication should arrive to the facility in the morning run. If it is a morning fax, it should come in the evening delivery. A stat delivery would be take around 4 hours since the pharmacy is in [NAME]. Residents Affected - Few 105372 Page 26 of 51 105372 02/14/2024 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

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** 2) Resident #60 was originally admitted to the facility on [DATE]. Diagnoses included Chronic Obstructive Pulmonary Disease. She receives Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/ML (milligrams per milliliter). She receives this every 6 hours for Chronic Obstructive Pulmonary Disease via nebulizer. A nebulizer is a drug delivery device used to administer medication in the form of a mist inhaled into the lungs. Residents Affected - Few On 02/11/24 at 10:51 AM, a nebulizer was observed on a table next to the resident with a bug crawling on it and not in a plastic bag (photographic evidence obtained). Based on observations, interviews, and record review, the facility failed to ensure respiratory equipment was stored in a manner to prevent infection for 2 out of 3 sampled residents for respiratory care (Residents #155 and #60). The findings included: Review of the facility's policy titled, Nebulizer Equipment Storage with a revised date of 02/2019 included: It will be the standard of this facility that nebulizer equipment will be stored according to current best practice guidelines. Between uses store nebulizer parts in a dry, clean plastic storage bag. 1) Record review for Resident #155 revealed the resident was admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). Review of the Minimum Data Set for Resident #155 dated12/19/23 revealed in Section C a Brief Interview of Mental Status score of 15 indicating a cognitive response. Review of the Physician's Orders for Resident #155 revealed an order dated 12/20/23 for Ipratropium-Albuterol Solution 0.5-2.5 (3) mg/3ml inhale orally via nebulizer four times a day related to Chronic Obstructive Pulmonary Disease. Review of the Physician's Orders for Resident #155 revealed an order dated 01/16/24 to change nebulizer set up and bag weekly and as needed. Review of the Care plan for Resident #155 dated 07/27/21 with a focus on the resident has potential for altered respiratory status/difficulty breathing related to COPD, SOB (Shortness of Breath). The goal was to have no complications related to SOB through the review date. The interventions included: Administer medication/puffers as ordered. Monitor for effectiveness and side effects. On 02/11/24 at 9:35 AM an observation was made of Resident #155's nebulizer mask sitting on top of nebulizer machine that is located on the floor. The nebulizer was not in a plastic bag. On 02/11/24 at 10:45 AM a second observation was made of Resident #155 nebulizer mask sitting on top of nebulizer machine that is located on the floor. The nebulizer was not in a plastic bag. During an interview conducted on 02/11/24 at 10:50 with Staff D Licensed Practical Nurse (LPN) who was assigned to Resident #155. Staff D LPN was asked if nebulizer masks need to be in a plastic bag when not in use, he stated they should be. Staff D LPN acknowledged the nebulizer mask for Resident 105372 Page 27 of 51 105372 02/14/2024 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0695 #155 was not in a bag and it was sitting on top of the nebulizer machine for Resident #155. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 105372 Page 28 of 51 105372 02/14/2024 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, it was determined that the facility failed to ensure that 1 (Resident #31) of 2 residents reviewed for dialysis did not receive services consistent with professional standards of practice that included ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. Residents Affected - Few The findings included: During the Dialysis review for Resident #31 on 02/13/24, it was noted that there was no evidence, written or computer, of communication with the dialysis center after each session. A request was made by the surveyor to the Director of Nursing (DON) on 02/13/24 for documentation of communication for all dialysis sessions concerning Resident #31. On 02/13/24 the DON informed the surveyor that the written documentation that was normally kept in a binder at the facility at the 100 Wing Nursing Station was missing. A review of the clinical record of Resident #31 noted that the resident had a current MDS BIMS score of 14. Further review noted diagnoses of Adjustment Disorder with Mixed Anxiety and Depressed Mood. Further review of the clinical record and interview with Resident #31 on 02/12-13/24 noted that all physician ordered medications are refused on a daily basis. Review noted refusals of routine and sliding scale insulin, antihypertensive medications, dialysis medications, antianxiety medication, and gastric enteral tube feedings. Due to the lack of dialysis communication it was unknown what medications and procedures are being refused at the dialysis sessions. Current physician orders originally dated 09/15/23 noted that the resident receives dialysis sessions 3 times per week (Monday/Wednesday/Friday). The facility was unable to provide communication reports from the dialysis center for the 09/15/23 date to present date on 02/12/24. It was noted that the resident was not in the facility from 02/7-9/24, 01/10-14/24, and 12/16-20/23. 105372 Page 29 of 51 105372 02/14/2024 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to provide sufficient staffing to accommodate resident's choices for being out of bed, to accommodate residents' participation in activities, and choices for having meals in the dining room. The insufficient staffing has the potential to affect all residents in the facility, including Residents #22, 56, 37 and a resident who wished to remain anonymous. The census at the time of the survey was 108 residents. 1). The Facility Assessment, most recently updated on 01/30/24, did not address the staffing needs to provide activities based on the facility census and the acuity of the residents being provided care. A review of the Activities Calendar for the month of February 2024 revealed the following: Each Sunday, the only activity is Bible Study at 2:45 PM. Each Thursday, the only activities are 'Biggest Loser' at 1:15 PM and Bingo at 2:30 PM. Each Saturday the only activities are Morning News and word search puzzles that are kept at the nurse's stations on the units and are individual activities done by the residents in their rooms. a. During an interview, on 02/11/24 at 1:37 PM, with the Activities Director, when asked about the activities, the Activities Director stated that Resident #49 leads the 'Bible Study' on Sundays. The Activities Director described the 'Biggest Loser' activity was for residents that had successfully lost weight. The Activities Director stated that the 'Morning News' was just turning the TV on in the residents' rooms. When this surveyor requested a schedule for activities staff, the Activities Director replied, I am the only one, I don't have a staff. There is no money in the budget for additional staff. b. During a meeting with members of the Resident Council, on 02/12/24 at 2:30 PM, including Resident #22, with a BIMS of 15, Resident #56, and a resident who wished to remain anonymous, with a BIMs of 15, when asked about activities, the resident who wished to remain anonymous replied, we don't even have a budget for activities. The Activities director said that there is no budget as well. We have a hard time getting people to come to activities. We used to have a lot of people in the dining room when the former FSD was here. Residents #22 and #56 voiced agreements with the statement made by the resident who wished to remain anonymous. Resident #56 stated, they didn't even get me out of bed until it was time for this meeting. The resident stated that she missed out on the 'Hot Chocolate' activity and that she would have participated had she been out of bed. The resident who wished to remain anonymous stated, Staff are always complaining that they are exhausted and tired. we don't even have a budget for activities. The Activities director said that there is no budget as well. We have a hard time getting people to come to activities. We used to have a lot of people in the dining room when [NAME] was here. Resident #56 stated, I was told that nobody wants to come to Activities except for Bingo. We don't eat lunch in the dining room on the weekends, because there is not enough staff. I have asked the 105372 Page 30 of 51 105372 02/14/2024 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0725 head cook and he said that there is not enough staff or enough people for us to eat in the dining room. Level of Harm - Minimal harm or potential for actual harm 2). On 02/12/24 at 12:12 PM, Resident #37 was observed in her wheelchair wearing a hospital gown. When asked why she was still wearing a gown, resident #37 replied, I don't know. Residents Affected - Few On 02/13/24 at 4:31 PM, Resident #37 was observed in bed. When asked about not participating in Bingo earlier in the day, Resident #37 replied, I don't know, I would like to go play Bingo. I've been in my bed all day. I want to get out of bed every day. I was out of bed yesterday. When asked about attending the 'Fat Tuesday Trivia' (Mardi Gras celebration), Resident #37 became upset about missing the activity. When asked why she did not attend, Resident #37 replied, I don't know, they didn't get me out of bed. 3). During an interview with Resident #56, on 02/12/24 at 11:02 AM, Resident #56 stated that she was not assisted out of bed the previous day until approximately 2:00 PM. Resident stated usually they don't get me out of bed at all (referring to being out of bed on the weekends). During a follow up interview, on 02/13/24 at 4:44 PM, with Resident #56, when asked about being out of bed, Resident #56 replied, Partly my choice and partly because the CNA says that they don't want to get me up because they are tired or don't feel like it. I used to get up every Sunday through Friday, and on Saturdays I would take to rest. Sunday to Friday I want to be out of bed at 10:30 every morning. 4). During an observation of lunch, on 02/11/24 at approximately 12:00 PM, it was noted that there were no residents eating the meal in the dining room. During the observation, which continued to the Hibiscus unit (Rooms #100 to 128) and the Dolphin unit (Rooms #200 to 222), Resident #56 was noted to still be in bed and served lunch in the room. On 02/11/24 at 12:22 PM, the Administrator reported to a survey team member that it was Resident Council's decision to not eat lunch in the dining room on the weekends. During an observation of lunch being served to the residents in their rooms on the Hibiscus and Dolphin units, on 02/12/24 at approximately 12:00 PM, Resident #56 was noted to be served in her room while still in bed. During a meeting with members of the Resident Council, on 02/12/24 at 2:30 PM, including Resident #22 with a Brief Interview for Mental Status (BIMS) score of 15, Resident #56 with a BIMS of 15, and a resident that wished to remain anonymous with a BIMS score of 15, when asked about having meals in the Dining Room, Resident #56 stated, We don't eat lunch in the dining room on the weekends, because there is not enough staff. I have asked the head cook and he said that there are not enough staff or enough people for us to eat in the dining room (referring to there not being enough staff to assist residents to the dining room). Resident #22 and the resident that wished to remain anonymous also stated that they preferred to eat in the dining room. During an interview, on 02/14/24 at 12:38 PM, with Staff Q, CNA, when asked about residents having meals in the dining room, Staff Q replied, some want the dining room and some don't. When asked about Resident #56 being in bed during lunch, Staff Q replied, I don't know, she is always in the dining room. 105372 Page 31 of 51 105372 02/14/2024 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0725 Level of Harm - Minimal harm or potential for actual harm During an interview, on 02/14/24 at 1:21 PM with the Food Service Director (FSD), when asked about residents wanting to eat meals in the dining room, the FSD replied, it is an ongoing battle. A lot are not even getting offered to go to the dining room. Residents Affected - Few 105372 Page 32 of 51 105372 02/14/2024 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to identify medications that were not supposed to be crushed for a resident with a PEG tube for 1 of 5 sampled residents reviewed for unnecessary medications (Resident #18). The findings included: Record review for Resident #18 revealed the resident was admitted to the facility on [DATE] with the most recent readmission date of 05/11/23 with diagnosis of Gastrostomy Status. Review of the Minimum Data Set for Resident #18 dated 12/23/23 revealed in Section C a Brief Interview of Mental Status was not conducted due to the resident is rarely/never understood. Review of the Physician's Orders for Resident #18 revealed an order dated 04/05/23 for Flomax oral capsule 0.4mg (Tamsulosin HCL) give 0.4 mg via PEG tube at bedtime. Review of the Physician's Orders for Resident #18 revealed an order dated 05/30/23 for Linzess oral capsule 290mcg give 290 mcg via PEG tube one time daily. Review of the Pharmacy Consultation Report for Resident #18 was as follows: 01/11/24 no recommendation 12/16/23 no recommendation 11/15/23 no recommendation 10/16/23 no recommendation 09/15/23 no recommendation 08/15/23 no recommendation During an interview conducted on 02/14/24 at 9:34 AM with the Consultant Pharmacist, she stated she has been the consultant pharmacist with the facility for a few years. When asked when she does the monthly pharmacy reviews if she reviews all of the medications for each resident, she said yes. When asked if some tablets and capsules can be crushed or opened, she said some can but not all. When asked about Resident #18 if she was aware of the resident having a PEG tube, she said yes, she was aware. When asked about Resident #18 and his order for Flomax capsule 0.4mg, she acknowledged that the capsule should not be opened to be administered via PEG tube. The Consultant Pharmacist stated Per the package label, the capsules should be swallowed whole and not crushed, chewed, or opened. The administration of tamsulosin through nasogastric, gastric, or jejunostomy tubes has not been formally evaluated by the manufacturer; reports suggest that the granules may adhere to the sides of the tube, which complicates administration and increases the risk of tube blockage. When asked about the Linzess 105372 Page 33 of 51 105372 02/14/2024 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0756 capsule 290mcg, the Consultant Pharmacist stated the capsule should not be opened per the manufacturer's instruction. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 105372 Page 34 of 51 105372 02/14/2024 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

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** 2) On 02/11/24 at 10:51 AM, a medication observation pass was conducted with Staff N, a licensed practical nurse (LPN). She was observed preparing 7 medications for Resident #60. One of the medication, Thiamine, was written in the Medication Administration Record (MAR) as Thiamine Capsule give 1 tablet by mouth one time a day for supplement. Staff N looked through the medication cart and only found Thiamine tablets. She stated that she could not give a tablet to the resident because the order said capsule and there were no capsules available in the facility. Staff N proceeded to administer the other medications to the resident. Thiamine is a vitamin. Residents Affected - Few Staff N did not inform the physician that the Thiamine was not administered and there was no note in the Electronic Health Record that she informed anyone that the facility did not have Thiamine capsules. Based on observations, interviews, and record review, the facility failed to ensure the medication error rate was not 5% or greater. The medication error rate was 10%, 3 medication errors were identified while observing a total of 30 opportunities, affecting Residents #4 and #60. The findings included: 1) Record review for Resident #4 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Anoxic Brain Damage, Chronic Obstructive Pulmonary Disease, Essential (Primary) Hypertension, and Tracheostomy Status. On 02/11/24 at 9:48 AM an observation was made of Staff C, Registered Nurse (RN), performing medication administration for Resident #4. The nurse obtained a blood pressure reading for the resident of 99/63. The nurse stated she was holding the following medications due to the low blood pressure: Amlodipine Besylate 10mg and Lasix (Furosemide) 20mg. Review of the Physician's Orders for Resident #4 revealed an order dated 01/12/24 for Amlodipine Besylate oral tablet 10mg give 1 tablet via PEG tube one time a day for high blood pressure. Review of the Physician's Orders for Resident #4 revealed an order dated 01/12/24 for Furosemide oral tablet 20mg give 1 tablet via PEG tube one time a day for Hypertension. Review of the medication administration record for Resident #4 for 02/11/24 revealed for the two medications, Amlodipine Besylate 10mg and Lasix (Furosemide) 20mg both were documented as not given. Review of the Nursing Progress Notes for Resident #4 for 02/11/24 revealed no documentation of the nurse having notified the physician of holding Amlodipine Besylate 10mg and Lasix (Furosemide) 20mg for low blood pressure. During an interview conducted on 02/11/24 at 10:30 AM with Staff C, RN, who was asked about holding blood pressure medications, she said if the nurse thinks the blood pressure is low, we hold the blood pressure medications. She acknowledged Resident #4 did not have parameters to hold the Amlodipine Besylate 10mg and Lasix (Furosemide) 20mg. During an interview conducted on 02/11/24 at 11:45 AM with Staff C, RN, she acknowledged she did 105372 Page 35 of 51 105372 02/14/2024 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0759 not notify the physician about holding any medications for Resident #4. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 105372 Page 36 of 51 105372 02/14/2024 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to ensure reasonable efforts to accommodate individual food preferences, dietary needs, and food quality related complaints for 9 sampled residents that include: Resident's #22, #32, #39, #46, #49, #51, #56, #57, #66, and one resident who requested to stay anonymous. The findings included: 1) During the screening of Resident #39 on 02/11/24 at 10:15 AM, the alert and oriented resident was noted to state that the facility menu is either not posted to view or the posted menu is not followed on a regular basis. The resident further stated he was given the phone number of the kitchen to call food food requests or food issues, however he always gets the answering machine and leaves messages that are never returned. Further stated that he never is served food preferences and is sent food that the quality is terrible and does not eat the meals. On 02/13/24 at 9 AM Resident #39 interviewed again concerning his meal issues and stated no posted menu, if posted the menu is not followed, food preferences not followed, and food is terrible. During the review of the clinical record of Resident #39 on 02/13/24 it was noted an admission date of 10/16/23 and has a current physician ordered regular diet (large portions). The resident's current MDS BIMS Score is 15 (no cognition issues. 2) During the screening of Resident #46 on 02/11/24 at 10:30 AM, the alert and oriented resident stated to the surveyor that the facility food is terrible and poor quality (appearance, taste, not palatable). Further stated that food preferences are not followed and the facility menu is not followed on a daily basis. Stated she has expressed her concerns to the dietary department without resolution. Stated she refuses numerous meals due to the quality of the food. 1/20/24) Observations of the resident's breakfast and lunch meals noted in take of less than 25%. Review of the clinical record of Resident #46 on 02/13/24 noted admission date of 05/01/22, physician ordered Regular Diet, and an MDS (01/20/24) BIMS Score of 13 (no cognitive impairment). 3) During the screening of Resident #66 on 02/11/24 at 10:40 AM, the alert and oriented resident stated to the surveyor the the facility food is either undercooked or overcooked and cannot eat many meals. Further stated he would like to receive a menu that will be followed on a daily basis. Stated he has complained to dietary staff numerous times concerning the quality of the food but nothing has changed. Observation of the breakfast meal on 02/12/24 at 9:15 AM and the lunch meal on 02/12/24 at 12:35 PM noted that resident intake was less than 25 %. Also stated he is being sent a Milkshake on meal trays but will not drink because of the fructose content of the milkshake, and requested the surveyor to help him with the meal quality and type of supplement being served. On 02/13/24 at 9:15 AM, a second interview noted the resident again confirmed the food preparation issues, poor food quality, and lack of menu. A review of the clinical record of Resident #66 on 02/13/24 noted an admission date of 04/01/22, with current physician order for a Carbohydrate Controlled/Mechanical Soft Diet. A review of the 105372 Page 37 of 51 105372 02/14/2024 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0800 resident current MDS (11/30/23) noted a BIMS Score of 13 (no cognitive impairment). Level of Harm - Minimal harm or potential for actual harm 6). Resident #32 was admitted to the facility on [DATE]. Resident #32's diet orders included: Consistent Carbohydrate Diet (CCD) diet Regular texture, thin consistency - double portions - 10/03/22. Residents Affected - Some During an interview with Resident #32, a resident with a BIMS score of 15, on 02/11/24 at 9:41 AM, when asked about the food being served in the facility, Resident #32 replied, they are always missing juices, sugar, sweet and low, creamers - condiments for coffee Resident #32 stated that the concern had been ongoing for a couple of months. Resident #32 further stated, If you don't like it on the menu, you can ask for a salad, but sometimes they don't have the tomatoes, lettuce - stuff to make a salad with. They keep not having cottage cheese - I hear other residents asking about it. 7). On 02/11/24 at 10:09 AM, the Food Service Director was observed replacing the lunch menu that was posted outside of the kitchen. When asked why the menu was being changed, the FSD replied, 'Cauliflower hasn't come in yet on the truck so we are changing it to capri vegetables (a mixture of carrots, broccoli, green beans and cauliflower). 8). Resident #56 was admitted to the facility on [DATE]. Resident #56's diet orders included: Consistent Carbohydrate, No Added Salt (CCD, NAS) diet, Regular texture, thin consistency - large portions protein and vegetable per resident request - 06/25/23. During an interview with Resident #56, a resident with a BIMS score of 15, on 02/11/24 at 10:49 AM, when asked about the food being served in the facility, Resident #56 replied, My daughter brings me food 3 times a week. The Administrator won't let them order the right supplies that they need. The budget is in her hands. There is not enough food for all the people that live here. 9). Resident #49 was admitted to the facility on [DATE]. Resident #49's diet orders included: Regular Diet, regular texture, Thin Consistency - Larger portions protein all meals for Weight Maintenance - 01/11/23. During an interview with Resident #49, a resident with a BIMS score of 15, on 02/11/24 at 11:41 AM, when asked about the food being served in the facility, Resident #49 replied, I have to keep sugar because they run out of sugar for my coffee about every other week. They run out of milk for 6 days at a time. The juices run out. 10). During an interview, on 02/12/24 at 2:30 PM, with members of the Resident Council, including Resident #56 with a BIMS score of 15, Resident #22 with a BIMS score of 15, and a resident who wished to remain anonymous with a BIMS score of 15, when asked about the food being served in the facility, the resident who wished to remain anonymous replied, they are running out of stuff all of the time because the people are stealing. They are always out of lettuce and tomatoes. Resident #56 stated, No tomatoes today. At least twice a week they are not serving what is on the menu. They don't have it. The FSD buys milk out of their pocket. The resident who wished to remain anonymous stated, The FSD says that it is not in the budget as an excuse for running out of food. Resident #22 stated, they are having parties for themselves and they don't have a budget for us to have food. 105372 Page 38 of 51 105372 02/14/2024 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 4) Resident #51 was admitted to the facility on [DATE] with diagnoses that included Quadriplegia, Adult Failure to Thrive, and Hypertension. His diet was No added salt, regular texture. His Brief Interview for Mental Status (BIMS) score was 13 on the quarterly Minimum Data Set (MDS) dated [DATE]. This indicated the resident was cognitively intact. An interview was conducted with the resident on 02/11/24 at 11:48 AM. The resident stated he does not have a choice of what he gets for food and can't ask for a substitute because he is not aware what alternate meal is available. He also stated he stays in his room and alternate menu is not available for him to see. His friends bring him snacks so he eats them when he doesn't like what was served. He is told when the meal is delivered that this is what the kitchen made by the staff who delivers the meals. On 02/13/24 at 9:12 AM, an interview was conducted with Staff H, Dietetic Technician, who has been with the facility since November 2023. She was asked about how residents can receive substitutions. On 2/13/24 at 11:00 AM Staff H revealed that she spoke with the resident and gave him an alternate meal menu. 5) Resident #57 was admitted to the facility on [DATE] with diagnoses that included Acute Myocardial Infarction, Acute Kidney Failure and Dementia. His BIMS score was 10 on the quarterly MDS dated [DATE]. This indicated the resident had cognitive impairment. He had a regular diet with regular consistency. On 02/12/24 at 10:51 AM the resident stated that he receives hard boiled eggs every morning and wants something different. He also stated that he is kosher so when pork is served he always gets peanut butter and jelly. He does not know what is on the menu since he does not leave his room. On 02/13/24 at 9:12 AM, an interview was conducted with Staff H, Dietetic Technician, to discuss Resident #57's concerns regarding alternate meals. Staff H stated she will speak with the resident. On 2/13/24 at 11:00 AM Staff H revealed that she spoke with the resident and gave him an alternate meal menu when pork is served. A weekly menu was reviewed with the resident and placed on file with dietary. 105372 Page 39 of 51 105372 02/14/2024 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review, it was determined that the facility's approved menu was not prepared in advance and not followed and not reviewed by the facility's dietitian or other qualified nutrition professional, for potentially 75 facility residents. The findings included: 1) During the review of the approved menu for the lunch meal of 02/11/24 it was noted that the menu for Regular, Therapeutic, and Mechanically Altered Diets included: Apple Pork Chops Onion Roasted Potatoes Dill Carrots Roll Pineapple Chunks During the observation of the lunch meal in the main kitchen on 02/11/24 at 9 AM, it was noted that the Cook, Staff E, was preparing canned Beef Ravioli , Carrots, and Pears Halves. The surveyor requested Staff E to provide a copy of the approved lunch menu and replied that she did not have a copy of the approved lunch menu. Staff E provided the surveyor a menu that she stated was left for her by the Food Service Director to prepare for the lunch meal that only included; Ravioli, Vegetable Blend , Garlic Bread, and Pears. The menu did not document portion sizes to be served or specific serving of therapeutic diet, and mechanically altered diets. On 02/11/24 at approximately 10 AM the Food Service Director (FSD) appeared in the main kitchen and was immediately interviewed by the surveyor concerning the lunch menu. The FSD stated that they were substituting the approved dinner menu for 02/11/24 because there were cans (#10) in the store room that were about to expire during February 2024. At the request of the surveyor the cans of Beef Ravioli were taken out of the trash and were noted to all have an expiration date of February 2025. Further interview with the FSD noted that the truth was not told to the surveyor and it was further noted that the Pork Chops were not ordered for timely delivery for the preparation of the lunch meal of 02/11/24. Observation of the lunch meal of 02/11/24 at 11:30 AM revealed pureed Ravioli was not prepared for the 6 physician ordered pureed diets and it was noted that pureed beef was served. The cook stated that she did not have a lunch menu to follow for pureed diets. Further interview with the FSD on 02/11/24 at 10 AM noted that the approved menu for the dinner meal of 02/11/24 would be substituted for the lunch meal of 02/11/24. A review of the approved menu for the dinner menu of 02/12/24 that would be substituted for the lunch meal of 02/11/24 included: 105372 Page 40 of 51 105372 02/14/2024 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0803 Cabbage Soup Level of Harm - Minimal harm or potential for actual harm Ham Sandwich Pickled Beet Residents Affected - Few Pineapples & Oranges During the interview the surveyor requested to see if all the dinner menu items were in stock and it was noted that the Canned Beets (Pickled Beets) and Pineapple and Oranges were not in stock. The FSD stated that Brussels Sprouts would be substituted for the Pickled Beets and had not determined what the dessert would be. Further stated that the canned Beets were not ordered on a timely basis. During the interview with the FSD on 02/11/24 at 10 AM it was discussed that the substitutions of the approved menu for the lunch and dinner menus cannot be conducted without the approval of the facility's Registered Dietitian to ensure that the menu meets the nutrition needs of the residents and that therapeutic and mechanically altered diets are followed to meet the needs. 2) During the observation of the lunch meal on 02/13/24 at 11:30 AM, it was noted that the approved menu for Regular, Therapeutic, and Mechanical altered diets all included the vegetable serving as Cauliflower. Interview with the Corporate Food Service Director (CFSD) at the time of the observation noted that Capri Vegetables would be substituted for the Cauliflower. The CFSD stated that the facility Food Service Director failed plan the menu one week in advance and that the cauliflower was not ordered in time for the lunch meal of 02/13/24. 3) During the review of the approved menu for the lunch meal of 02/14/24 it was noted that the dessert to be served to Regular, Therapeutic and Mechanically Altered Diets was Dreamsicle Gelatin. Observation of the lunch meal in the main kitchen on 02/14/24 at 11:45 AM noted that Apple Pie had been substituted for the Dreamsicle Gelatin. Interview with the Corporate Food Service Director on 02/14/24 noted that the ingredients for the Dreamsicle Gelatin that included: Orange Gelatin Mix, Instant Vanilla Pudding, Mandarin Oranges, and Whipped Cream were not purchased. 4) Refer to F 800 for interviews with Residents #39, #46, and #66, conducted on 02/11/24-02/13/24, for complaints voiced to the surveyor that the menu is either not posted or if posted it is not followed. They stated that they are not aware what will be served for the breakfast, lunch and dinner. The residents stated they have complained without resolution. 105372 Page 41 of 51 105372 02/14/2024 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, it was determined facility foods were not palatable and not prepared by methods that conserve nutritive value, flavor, and appearance for potentially 75 of 75 of the facility's residents. Residents Affected - Few The findings included: 1) During the observation of the lunch meal of 02/11/24 at 10 AM in the main kitchen, it was noted that the approved lunch menu of Pork Chops, Dilled Carrots, Onion Roasted Potatoes, and Pineapple Chunks would be substituted with Beef Ravioli, Cooked Carrots, Tomato Soup, and Pears. During the meal service conducted in the main kitchen on 02/11/24 at 11:45 AM, it was noted that the meal was not appetizing/appealing due to orange color from the Ravioli (tomato sauce) , Carrots, and Tomato Soup. Interview conducted with the lunch [NAME] (Staff E) at the time of the meal observation, and she stated that she was not given a menu to follow for the lunch meal and was unaware of how unappetizing the meal appearance was. A review of the facility's Standardized Recipe for the preparation of Cheese Ravioli noted that the ingredients to be utilized in the preparation included Frozen Cooked Jumbo Cheese Ravioli with Meatless Spaghetti Sauce that are mixed and baked in the oven for 30 minutes. 2) During the review of the approved menu for the lunch meal of 02/12/24 it was noted that entrée of Maple Glazed Fish and Garden [NAME] Blend (starch) to be served. At the request of the surveyor the Standardized recipe for the Maple Glazed Fish and Garden [NAME] Blend were requested and reviewed. The review of the standardized recipe for Maple Glazed Fish noted the following ingredients to be included in the fish preparation: * [NAME] Sugar * Maple Syrup * Lite Soy Sauce * Ground Ginger The review of the standardized recipe for Garden [NAME] Blend noted the following ingredients to be included in the rice preparation: * Garden [NAME] Blend (Commercially Packaged) * Margarine During the the observation of the lunch meal service in the main kitchen on 02/12/24 at 11:40 AM the fish entree and rice blend did not appear to be what the approved menu documented. The lunch cook (Staff E ) was interviewed concerning the preparation of the fish and rice. The [NAME] (Staff E) responded that she did not use the standardized recipe for the fish and rice preparation. The surveyor reviewed the recipes with the Cook, who stated none of the ingredients listed were included in the 105372 Page 42 of 51 105372 02/14/2024 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few preparation of the fish and rice. Staff E stated that only spices were added to the fish and only peas were added to the prepared white rice. She also stated she did not know where the standardized recipes are located and does not follow recipes on a regular basis. 3) During the observation of the lunch meal of 02/12/24 at 11:45 AM, in the main kitchen, it was noted that the pan of Broccoli located in the steam table was pale in color (yellowish) and soggy in consistency. Interview with the lunch [NAME] (Staff E) at the time of the observation stated that she was unaware that prolonged cooking of vegetables would negatively effect the appearance , palpability, and nutritive value. The Corporate Food Service Director also viewed the broccoli and agreed with the surveyor's observation. 4) During the observation of the lunch tray assembly line in the main kitchen on 02/12/24 at 11:30 AM, it was noted that a Chef Salad was located on a cart at room temperature. Interview with the lunch cook (Staff E) why the Chef Salad was not in ice or refrigeration to ensure that the temperature of the perishable foods were maintained at the regulatory temperature of 41 degrees F or below. Staff E responded that she was unaware of regulatory temperature requirements. At the request of the surveyor the ingredients of the Chef Salad were taken by the Corporate Food Service Director (CFSD) with the use of the facility's calibrated digital food thermometer. The temperatures were recorded as follows: Boiled Egg Slices: 52 degrees F Turkey Strips: 53 degrees F Cheese Strips: 63 degrees F Copped Lettuce: 68 degrees F Following the observation and food temperature testing, it was discussed with the CFSD that resident foods (salads) are not being kept at regulatory requirements which effects the palability of foods being served to the residents. 105372 Page 43 of 51 105372 02/14/2024 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview, and record review, it was determined that the facility failed to prepare pureed foods in a consistency designed to meet the needs of 6 (includes Resident #12) physician ordered pureed diets. The findings included: During the observation of the lunch meal in the main kitchen on 02/13/24 at 11:30 AM, it was noted that the approved menu documented pureed Turkey Goulash and pureed Cauliflower (sub Capri Vegetables). Observation of the tray assembly line noted visible pieces of Turkey were in the Turkey Goulash and visible pieces of vegetables were in the pureed Capri Vegetables. A taste test of the entrée and vegetables conducted by the surveyor and the Lunch [NAME] (Staff F) confirmed pieces of turkey and vegetables in the pureed mixtures. Interview conducted with Staff F at the time of the observation noted that he does not taste test pureed foods to ensure that the pureed mixture is smooth in consistency. Also noted that Staff F was not aware that dysphagia pureed foods must be smooth in consistency when there is a diagnoses of Dysphagia. Review of 02/11/24 and 02/13/24 diet census noted that there were currently 6 facility residents with physician ordered pureed diets (Including Resident #12). Review of the facility's Approved Diet Manual _ Consistency Modified Diets (Pureed) on 02/13/24 documented foods should be Pudding Like with no coarse textures. Any foods that require bolus formation or mastication are excluded. Diet is designed for people with moderate to severe dysphagia. Thin liquids should be thickened as ordered. 105372 Page 44 of 51 105372 02/14/2024 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

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 observation and interview, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety that ponteitiall effected 75 of the facility's residents. The findings included: 1) During the initial kitchen/food service observation tour conducted on 02/11/24 at 8:45 AM, there was no dietary supervisor present. The following were noted during the tour: a) Numerous small black flying insects noted to be in the food preparation and serving area. (b) Upon entering the kitchen it was noted a 1/3 steam table pan of pureed vegetables (10 portions) and 1/3 steam table pan of pureed beef sitting out at room temperature. The breakfast [NAME] (Staff A) stated that the pans included pureed mixed vegetables and pureed ground beef which were prepared earlier in the morning. At the request of the surveyor the temperature of the foods were tested using the facility's calibrated digital food thermometer. The temperatures were recorded as follows: pureed beef 110 degrees F and pureed vegetables 108 degrees F. The surveyor informed the [NAME] (Staff A) that these perishable foods need to kept at the regulatory temperature of 41 degrees F or below or 141 degrees F or above. (c) During the tour Staff A was noted to be taking the temperature of the Beef Ravioli that was the lunch entrée. Further observation noted that Staff A would take the temperature without sanitizing the thermometer prior to testing the food temperature. Staff A stated to the surveyor that the alcohol pads that are being utilized to sanitize the thermometer are locked in the Food Service Directors office and are not available. (d) During the tour it was noted that 2 of 3 red buckets being utilized for sanitized cleaning cloth storage were empty with soiled rags left inside. Staff were noted to be utilizing the soiled rags to clean food preparation surfaces. (e) Observation of the walk-in refrigerator noted that the outside wall/entrance area was heavily soiled, rusted, and mold laden. (f) Observation of the commercial table mounted can opener noted that the blade cutting area was heavily soiled with metal shavings, dried food matter, and black mold type matter. (g) The 2 - wall mounted air-conditioner vents located above the entrance to the walk-in refrigerator was noted to be black in color due to a build-up of dust and black mold type mater. (h) Observation of the wall and entrance to the walk-in freezer was noted to be heavily soiled and rust laden. (i) Observation of the walk-in freezer noted that foods were not properly covered. Specifically a case of chocolate chip cookies and hamburgers (30 ind) was open to the freezer air and were also noted to be freezer burned. 105372 Page 45 of 51 105372 02/14/2024 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many (j) During the observation of the dish machine area it was noted that numerous floor tiles in front of the machine were broken and missing. Soiled water was noted to be accumulating in the floor area were the missing tiles were broken/missing. The exterior of the commercial garbage disposable was rust laden. (k) Observation of the color-coded cutting boards (4 of 4 ) were noted to be heavily worn with deep knife cuts and areas of black mold type matter. (l) The ceiling vents (3) located above the food preparation area and food serving areas were noted to be black in color due to the build-up dust and black mold type matter. (m) The exterior of the wall and floor area at the hallway exit door was in heavy disrepair due to wall damage and broken tiles (8). 2) On 02/12/24 at 11 AM, a meeting was conducted with the Corporate Food Service Director (CFSD). During the meeting the surveyor conducted a tour with the CFSD and the sanitation violations originally observed on 02/11/24 were pointed out and acknowledged. 3) During the observation of the tray line assembly lunch meal in the main kitchen on 02/12/24 at 11:30 AM, it was noted that a Chef Salad was left out at room temperature and was located in a cart next to the tray line. At the request of the surveyor the temperature of the Chef Salad ingredients was taken by the CFSD with the facility's calibrated digital food thermometer. The findings on the temperature test noted that the perishable salad ingredients were not being held at the regulatory requirement of 41 degrees F or below. The ingredient temperatures were recorded as follows: Boiled Egg Slices = 52 degrees F Turkey Slices = 63 degrees F Cheese Slices = 63 degrees F Following the temperature testing the surveyor requested to the CFSD that the salad not be served. 105372 Page 46 of 51 105372 02/14/2024 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to maintain accurate and complete medical records for 2 of 34 residents in the final sample (Residents #29 and #92). The findings included: Review of the Frequently Asked Questions About a Do Not Resuscitate Order (DNRO) located at https://www.floridahealth.gov/licensing-and-regulation/trauma-system/_documents/dnro-faq.pdf included: Does it have to be notarized or witnessed? No, the form is simply signed by the patient, health care surrogate or health care proxy as defined in section 765.202, Florida Statutes, and the patient's physician. This is a physician's order. 1.) Record review for Resident #29 revealed the resident was admitted to the facility on [DATE] with most recent readmission on [DATE] with diagnoses that included: Multiple Sclerosis, Tracheostomy Status, Gastrostomy Status, Paraplegia, and Neuromuscular Dysfunction of Bladder. Review of the Minimum Data Set (MDS) for Resident #29 dated 01/25/24 revealed in Section C a Brief Interview of Mental Status (BIMS) was not conducted due to the resident is rarely/never understood. Review of the Physician's Orders for Resident #29 revealed an order dated 01/08/24 for Do Not Resuscitate (DNR). Review of the Care Plan for Resident #29 dated 09/02/23 with a focus on resident has Advanced Directives: DNR status. The goal was for the resident's advanced directives are in effect and their wishes and directions will be carried out in accordance with their advanced directives through the review. The interventions included: Notify physician of resident's wishes regarding life-prolonging procedures as needed. Review of the electronic medical record (EMR) for Resident #29 revealed 2 copies of the same DNR form, neither form signed by physician. During an interview conducted on 02/13/24 at 8:50 AM with the Director of Nursing (DON) who was asked where the DNR forms are kept, he stated they are kept in the DNR book at the nursing stations and uploaded into the residents' electronic medical record (EMR). During an interview conducted on 02/13/24 at 8:55 AM with Staff C, Registered Nurse (RN) she acknowledged the DNR form in the Resident #29's EMR was not signed by the physician. The DNR form in the DNR book at the nursing station did have a DNR form for Resident #29 signed by the physician. 2.) Record review for Resident #92 revealed the resident was admitted to the facility on [DATE] with the most recent readmission on [DATE] with diagnoses that included: Anoxic Brain Damage, Tracheostomy Status and Gastrostomy Status. MDS dated [DATE] revealed in Section C a Brief Interview of Mental Status (BIMS) was not conducted due to the resident is rarely/never understood. 105372 Page 47 of 51 105372 02/14/2024 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the Physician's Orders for Resident #92 revealed an order dated 11/20/23 for Durable Do Not Resuscitate. Review of the Care Plan for Resident #92 dated 09/23/23 with a focus on the resident has advanced directives: DNR (Do Not Resuscitate). The goal was resident's advanced directives are in effect and their wishes and directions will be carried out in accordance with their advanced directives through this review. The interventions included: Notify physician of resident's wishes regarding life-prolonging procedures as needed. During an interview conducted on 02/13/24 at 8:55 AM with Staff C, RN she acknowledged the DNR form in the Resident #92's EMR was not signed by the physician, she also acknowledged the DNR form for Resident #92 in the DNR book was not signed by the physician as well. During an interview conducted on 02/13/24 at 9:33 AM with the DON who stated they did have a signed DNR form for Resident #92 and had a copy of the DNR form for Resident #92 in his hand. When the DON was asked where he got the copy, he said it was in the social worker's office. 105372 Page 48 of 51 105372 02/14/2024 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.) On 02/13/24 at 11:32 AM wound care was observed for Resident #20 with Staff K, a licensed practical nurse (LPN), who is designated as the wound care nurse. Staff K stated she had been working in the facility for 2-3 years and for the last 1.5 years as a wound care nurse. Staff K was observed washing her hands, donning gloves, removing the old dressing, doffing her gloves, washing her hands then donning gloves to prepare to apply a new dressing to the wound. Residents Affected - Few Before applying the new dressing, Staff K touched the bedside table with her clean gloves then continued to apply the clean dressing. Discussed with Staff K after the wound care observation, that she should not have touched the bedside table after washing her hands and donning gloves. 4.) On 02/11/24 at 8:45 AM, an observation was made of Resident #31 sitting in her wheelchair with blood flowing down her left arm. Staff D, a licensed practical nurse (LPN), was observed applying a paper towel to the laceration (photographic evidence obtained). The facility's policy titled, Skin First Aid issued 10/15/17 revealed guidelines to care for minor cuts and scrapes. If needed, gently press the wound with a clean bandage or cloth. Based on observations, interviews, and record review, the facility failed to administer medications in a safe and sanitary environment for 1 of 4 residents observed for medication pass (Resident #4); failed to ensure medications are stored in a sanitary manner for 1 of 4 medication carts; failed to provide wound care in a sanitary manner for 1 of 2 residents sampled for wound care (Resident #20); and failed to provide care for laceration in a sanitary manner for 1 of 34 sampled residents (Resident #31). The findings included: Review of the facility's policy titled, Infection Control-Hand Hygiene with a revised date of 03/02/19 included: It is the policy of the facility to perform hand hygiene in accordance with national standards from the Centers for Disease Control and Prevention and the World Health Organization. Soap and water are required for hand hygiene when hands are visibly soiled, after caring for resident with diarrheal infection such as C difficile, after potential exposure to body fluid, before and after eating or handling food, and after personal use of toilet. Alcohol-based hand rub may be used for all other hand hygiene opportunities (e.g. when soap and water is not indicated per above) According to the World Health Organization, hand hygiene is to be performed: prior to caring for a resident, prior to performing a procedure such as blood glucose monitoring or catheter care, when moving from a contaminated body site to a clean body site such as when changing a brief or wound dressing, after caring for a resident including after removing gloves and after contact with the resident environment. Review of Injection safety per the CDC at the following location: https://www.cdc.gov/injectionsafety/patients.html#:~:text=Both%20needle%20and%20syringe%20must,(HBV)%2C%20and included the following: Both needle and syringe must be discarded once they have been used. It is not safe to change the 105372 Page 49 of 51 105372 02/14/2024 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few needle and reuse the syringe - this practice can transmit disease. Reusing a needle or syringe can put patients in danger of getting hepatitis C virus (HCV), hepatitis B virus (HBV), and HIV. Review of the facility's policy titled, Storage and Expiration Dating of Medications, Biologicals with a revised date of 08/07/23 included: Facility should ensure that food is not to be stored in the refrigerator, freezer, or general storage areas where medications and biologicals are stored. 1.) Record review for Resident #4 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Anoxic Brain Damage, Tracheostomy Status, Other Involuntary Movements. Review of the Minimum Data (MDS) for Resident #4 dated 01/18/24 revealed in Section C a Brief Interview of Mental Status (BIMS) score of 15 indicating a cognitive response. Review of the Physician's Orders for Resident #4 revealed an order dated 01/12/24 for Heparin Sodium Injection Solution 5000 units/ml. Inject 5000 units subcutaneously one time a day. During a medication administration observation conducted on 02/11/24 from 9:48 AM to 10:30 AM with Staff C, Registered Nurse (RN) for Resident #4 the medications administered to the resident included: Heparin Sodium 5,000 units/ml, inject 5000 units subcutaneous and Dorzolamide-Timolol 2%-0.5% 1 drop both eyes. Staff C, RN did not wash hands before donning gloves, she changed gloves 3 times during the medication administration observation and did not perform hand hygiene between glove changes. The nurse opened the eye drops and put them on a tissue with the open end touching the tissue before she administered the eye drops. The nurse utilized the same needle twice to inject the full amount of Heparin solution that was in the vial to the resident. During an interview conducted on 02/11/24 at 10:35 AM with Staff C, RN, she stated she knew she made some mistakes. When asked about hand hygiene prior to donning gloves and in between glove changes, she acknowledged she did not wash her hands before donning gloves or in between glove changes. When asked if the open end of the eye drops should touch the tissue, she said no, and she acknowledged the open end of the eye drop container touched the tissue before she administered the eye drops. When asked about the injection, she stated the needle does not hold all of the heparin, so she needed to do it twice. When asked why she did not use two separate needles, she stated, This is the only kind of needles we have. The nurse acknowledged she should have used 2 separate needles/syringes, one for each time she injected the resident. 2.) On 02/11/23 at 9:26 AM, during an observation of medication administration with Staff D, Licensed Practical Nurse (LPN) while the nurse was pulling medications out of his cart there was a disposable coffee cup with a lid in the medication drawer with multiple liquid medications. On 02/11/24 at 10:47 AM, a second observation was made of Staff D (LPN) pulling medications out of his cart the disposable coffee cup with a lid in the medication drawer with multiple liquid medications was still there. During an interview conducted on 02/11/24 at 10:47 AM with Staff D, LPN when asked about the coffee cup in the medication cart in the drawer with medications, he stated oh, that is not supposed to be there. Staff D LPN acknowledged it was an infection control issue. 105372 Page 50 of 51 105372 02/14/2024 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0909 Level of Harm - Minimal harm or potential for actual harm Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. Based on observation and interview, the facility failed to ensure a low air loss mattress was functioning for 1 of 2 residents reviewed for wound care (Resident #20). Residents Affected - Few The findings included: On 02/11/24 at 12:03 PM, during a tour of the facility, the air mattress on the bed for Resident #20 was observed off. The pump was not lit and the mattress was not firm (photographic evidence obtained). The resident was asked if the mattress felt different and he stated that it felt a little lower on one side. The sheets were not fitted on the bed and the resident was lying on the actual mattress in some areas. Resident #20 currently has a Stage 3 wound to his left hip. Discussed this observation with the wound care nurse, Staff K, on 02/13/24 at 11:30 AM. Staff K stated she checks all of the air mattresses Monday thru Friday when she is at the facility and was unsure who checks them on the weekends. 105372 Page 51 of 51