Health inspection·January 2, 2025

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure sufficient fluid intake and tube feeding to maintain proper hydration for 1 of 4 residents sampled for tube feeding (Resident #2). Residents Affected - Few The findings included: Record review for Resident #2 revealed the resident was originally admitted to the facility on [DATE] with most recent readmission on [DATE] with diagnoses that included in part the following: Nontraumatic Subarachnoid Hemorrhage from Intracranial Artery, Osteomyelitis of Vertebra, Sacral and Sacrococcygeal Region. Review of the MDS for Resident #2 dated 11/02/24 documented in Section C a BIMS could not be conducted due to resident is rarely/never understood. Review of the Physician's Orders for Resident #2 revealed an order dated 07/02/24 for two times a day Auto water flush at 60 ml/hour x 20 hours (1200 ml total water). Review of the Physician's Orders for Resident #2 reveled an order dated 09/19/24 for Enteral feed order two times a day Jevity 1.5 at 75 ml/hour x 20 hours via G-tube. Turn TF (tube feeding) off at 2:00 PM, turn TF on at 10:00 AM. (This would indicate the TF would only be infusing for 4 hours per day). During an observation conducted on 01/02/25 at 12:30 PM of Resident #2 lying in bed with trach and PEG tube. The feeding pump was on and connected to the resident with hold error alert. The tube feeding bottle was for Jevity 1.5 (formulary type) and a bag of water connected to the feeding pump. During an observation conducted on 01/02/25 at 12:50 PM of Resident #2 still lying in bed with the tube feeding pump on and connected to the resident with the hold error alert still on. During an observation conducted on 01/02/25 at 1:50 PM of Resident #2 still lying in bed but with the tube feeding pump turned off. During an interview conducted on 01/02/25 at 2:10 PM with Staff B, Registered Nurse (RN) who was asked about the tube feeding for Resident #2, she said the resident is receiving tube feeding and water. She acknowledged the order was for the tube feeding to be turned off at 2:00 PM and on again at 10:00 AM. During an interview conducted on 01/02/25 at 2:22 PM with Staff E, Dietetic Technician who stated Page 1 of 9 105372 105372 01/02/2025 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few she has worked at the facility since July 2024. When asked to verify the tube feeding orders for Resident #2 specifically what time the tube feeding for the resident is to start and stop, she acknowledged tube feeding order was incorrect and it stated the instructions read to turn the tube feeding on at 10:00 AM and off at 2:00 PM, but the instructions for the tube feeding should read turn the tube feeding on at 2:00 PM and off at 10:00 AM. When asked if she checks to make sure the tube feeding orders are being followed, she said yes she checks the pumps periodically. 105372 Page 2 of 9 105372 01/02/2025 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** Based on observation, interviews and record review, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care is provided such care, for 3 out of 5 sampled residents with tracheostomy (Resident #3, #2, and #4) and failed to ensure trach tube at bedside for 2 out of 5 sampled residents for tracheostomy (Residents #4 and #5). Residents Affected - Some The findings included: Review of the facility's policy titled, Tracheostomy Care and Suctioning with an issued date of 03/26/21 included in part the following: The facility will ensure that residents who need respiratory care, including tracheostomy care and tracheal suctioning, is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan and resident goals and preferences. Procedures: 2 The facility will provide necessary respiratory care and services such as oxygen therapy, treatments, mechanical ventilation, tracheostomy care and/or suctioning. 3 Tracheostomy care will be provided according to the physician's orders. 5 The facility will ensure staff responsible for providing tracheostomy care including suctioning are trained and competent according to professional standards of practice. 1.) Record review for Resident #3 revealed the resident was originally admitted to the facility on [DATE] with most recent readmission on [DATE] with diagnoses that included in part the following: Chronic Respiratory Failure with Hypoxia, Tracheostomy Status, and Dysphagia. Review of the Minimum Data Set (MDS) for Resident #3 dated 09/26/24 documented in Section C a Brief Interview of Mental Status (BIMS) score of 13 indicating a cognitive response. Review of the Physician's orders for Resident #3 revealed an order dated 08/11/23 for trach care BID (twice daily) and PRN (as needed). Review of the Physician's orders for Resident #3 revealed an order dated 08/11/23 for SX (Suction) and lavages every shift and PRN (as needed). Review of the Respiratory Administration Record for Resident #3 from 01/01/25 to 01/02/25 revealed no documentation of the trach care or suctioning provided. Review of the Care Plan for Resident #3 dated 06/20/23 with a focus on the resident has a tracheostomy related to impaired breathing mechanics. The goals were for the resident to have no s/s (signs/symptoms) of infection, and will wean as tolerated. The interventions included: Administer respiratory treatments as ordered. Coordinate care with Respiratory Therapy. Maintain trach per MD orders. On 01/02/25 at 12:03 PM, an observation was made of Resident #3 sitting on edge of his bed, he has a trach in place and tube feeding that was infusing via a PEG tube. 105372 Page 3 of 9 105372 01/02/2025 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0695 Level of Harm - Minimal harm or potential for actual harm During an interview conducted on 01/02/25 at 12:03 PM with Resident #3 who was asked if staff provide trach care for him, he said no he does it himself. He said they give him the supplies and he cleans his trach himself once a day. When asked if staff care for his PEG tube, do they wear any PPE (Personal Protective Equipment) including a mask, gown and gloves, he stated they always wear gloves, some wear a mask, and none ever wear a gown. Residents Affected - Some During an interview conducted on 01/02/25 at 12:20 PM with Staff A, Registered Nurse (RN) who stated she has worked at the facility for 3 months. When asked about Resident #3 if he has a trach she said yes. When the RN was asked if she provides trach care for Resident #3, the nurse tried using her phone to translate and asked the ADON (Assistant Director of Nursing) for assistance. When the ADON asked the RN if she had ever provided trach care for Resident #3, she said no, that is respiratory. 2.) Record review for Resident #2 revealed the resident was originally admitted to the facility on [DATE] with most recent readmission on [DATE] with diagnoses that included in part the following: Nontraumatic Subarachnoid Hemorrhage from Intracranial Artery, Osteomyelitis of Vertebra, Sacral and Sacrococcygeal Region. Review of the MDS for Resident #2 dated 11/02/24 documented in Section C a BIMS could not be conducted due to resident is rarely/never understood. Review of the Physician's Orders for Resident #2 revealed an order dated 05/14/24 for trach care BID (twice daily) and PRN (as needed). Review of the Treatment Administration Record for Resident #2 from 0101/25 to 01/02/25 revealed no documentation of trach care provided. Review of Nurse Progress Notes for Resident #2 from 01/01/25 to 01/02/25 revealed no documentation of trach care being performed. 3.) Record review for Resident #4 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Acute and Chronic Respiratory Failure with Hypoxia, Tracheostomy Status, and Gastrostomy Status. Review of the MDS for Resident #4 dated 10/29/24 documented in Section C a BIMS score of 3 indicating severe cognitive impairment. Review of the Physician's Orders for Resident #4 revealed an order dated 07/24/24 for suctioning and lavages every shift and PRN. Review of the Physician's Orders for Resident #4 revealed an order dated 07/24/24 for trach care BID and PRN. Review of the Respiratory Administration Record, Medication Administration Record, and Treatment Administration Record for Resident #4 for 01/01/25 and 01/02/25 had no documentation for trach care BID and PRN. Review of the Care Plan for Resident #4 dated 07/25/24 with a focus on the resident has a tracheostomy related to impaired breathing mechanics. The goals were for the resident to have no s/s (signs/symptoms) of infection and will wean as tolerated. The interventions included in part the following: 105372 Page 4 of 9 105372 01/02/2025 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Administer respiratory treatments as ordered, Coordinate care with Respiratory Therapy, Maintain trach per MD orders. Tube Out Procedures: Keep extra trach tube and obturator at bedside. During an interview conducted on 01/02/25 at 12:27 PM Staff B, Registered Nurse (RN) who stated she has been working at the facility for 4 years. When asked if trach care is provided and by whom for residents who have a trach, the RN stated the nurses provide the trach care. When asked how often, she said every shift and as needed. When asked where extra trach tubes are kept, she said each resident has one at the bedside in the drawer and there are additional ones on the respiratory cart in the hallway. Staff B, Registered Nurse (RN) did side by side observation in rooms for Residents #2, #4, and #5 and acknowledged each resident did not have an extra trach tube at their bedside. When asked if she would know what size tube each resident would need if she had to get one from the respiratory cart in the hallway, she said no, she would have to look it up in the resident's chart. When asked if she had training on trach care she said yes they all had to do it last month. When asked if she feels comfortable doing the trach care and suctioning, she said I don't feel really comfortable, but I can do it. 4.) Record review for Resident #5 revealed the resident was originally admitted to the facility on [DATE] with most recent readmission on [DATE] with diagnoses that included in part the following: Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side, Tracheostomy Status, and Paralysis of Vocal Cords and Larynx. Review of the Minimum Data Set for Resident #5 dated 11/02/24 documented 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 #5 revealed an order dated 12/26/24 for trach - may suction and lavages resident via trach every shift for trach suction. Review of the Physician's Orders for Resident #5 revealed an order dated 12/26/24 for trach - provide trach care every evening and night shift. During an interview conducted on 01/02/25 at 12:55 PM with Staff C, Respiratory Therapist (RT) who stated he has been working at the facility since 4-5 years. When asked about trach care being provided for residents, he said the nurses now do the trach care including suctioning for the residents with trach, he only cares for the resident on ventilator. He said the transition happened about a week or two ago. During an interview conducted on 01/02/25 at 1:05 PM with the wife of Resident #5 who stated she is in the facility for 3-5 hours 5 days a week and other family members come in at various days/times to check on her husband including her son who is a Respiratory Therapist. When asked if the staff provide trach care and suctioning, she said they do but recently the respiratory therapist no longer provide the care, the nurses do, and she feels they do not feel completely comfortable doing the respiratory care. She went on to say if she feels her husband needs to be suctioned, the nurse sometimes will say he was just suctioned, but she feels that her husband needs to be suctioned again, the Respiratory Therapist used to do this in the past because sometimes he would need to be suctioned twice in a very short amount of time due to having a mucous plug. She said she is fully aware of what to look for regarding her husband's trach as her son the respiratory therapist taught her. During an interview conducted on 01/02/25 at 4:30 PM with Staff D, Licensed Practical Nurse (LPN) who stated she has worked at the facility for 1 year. When asked if she had received training for 105372 Page 5 of 9 105372 01/02/2025 Avante at Lake Worth, Inc. 2501 N A St Lake Worth, FL 33460

F 0695 Level of Harm - Minimal harm or potential for actual harm trach care and suctioning, she said yes they all had to do training with the Respiratory Therapist and return demonstration on a dummy in the classroom setting. When asked if she feels comfortable doing the trach care and suctioning, she said she feels good about doing it. Residents Affected - Some 105372 Page 6 of 9 105372 01/02/2025 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** Based on observations, interviews and record review, the facility failed to wear Personal Protective Equipment (PPE) mask appropriately when providing trach suctioning for residents on Enhanced Barrier Precautions (EBP) for 1of 1 resident observed for tracheostomy suctioning (Resident #5) and failed to ensure PPE (including disposable gowns) was readily available for 9 out of 9 residents with tracheostomy and failed to have EBP signage on door for resident with trach and PEG tube (Resident #3). Residents Affected - Some The findings included: Review of the facility's policy titled, Enhanced Barrier Precautions with an issued date of 04/01/24 included in part the following: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Policy Explanation and Compliance Guidelines: 3. Implementation of Enhanced Barrier Precautions: a. Make gowns and gloves available immediately near or outside of the resident's room. Note: face protection may also be needed if performing activity with risk of splash or spray (i.e., wound irrigation, tracheostomy care). 1.) During a tour of the facility was conducted on 01/02/25 at 9:00 AM. There were no gowns (Personal Protective Equipment) located in any caddies in 3 out of 3 units of the facility. 2.) Record review for Resident #3 revealed the resident was originally admitted to the facility on [DATE] with most recent readmission on [DATE] with diagnoses that included in part the following: Chronic Respiratory Failure with Hypoxia, Tracheostomy Status, and Dysphagia Oral Phase. Review of the Minimum Data Set (MDS) for Resident #3 dated 09/26/24 documented in Section C a Brief Interview of Mental Status (BIMS) score of 13 indicating a cognitive response. Review of the Physician's orders for Resident #3 revealed an order dated 08/11/23 for trach care BID (twice daily) and PRN (as needed). Review of the Physician's orders for Resident #3 revealed an order dated 08/11/23 for SX (Suction) and lavages every shift and PRN. Review of the Physician's orders for Resident #3 revealed an order dated 08/11/23 for trach tie changes on Monday AM. Review of the Respiratory Administration Record for Resident #3 from 01/01/25 to 01/02/25 revealed no documentation of the trach care or suctioning provided. On 01/02/25 at 12:00 PM, an observation was made of Resident #3's entrance to room with no Enhanced Barrier Precaution signage, and no gowns (Personal Protective Equipment) in close proximity to the resident's room or inside the resident's room. 105372 Page 7 of 9 105372 01/02/2025 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 - Some On 01/02/25 at 12:03 PM, an observation was made of Resident #3 sitting on edge of his bed, he has a trach in place and tube feeding that was infusing via a PEG tube. During an interview conducted on 01/02/25 at 12:03 PM with Resident #3 who was asked if staff provide trach care for him, he said no he does it himself. He said they give him the supplies and he cleans his trach himself once a day. When asked if staff care for his PEG tube, do they wear any PPE (Personal Protective Equipment) including a mask, gown and gloves, he stated they always wear gloves, some wear a mask, and none ever wear a gown. During an interview conducted on 01/02/25 at 12:20 PM with Staff A, Registered Nurse (RN) who stated she has worked at the facility for 3 months. When asked about Resident #3 if he has a trach and Peg tube, she said yes. When asked if he is on EBP, she said she did not understand and pulled out her phone to translate from English to Spanish. The RN still did not seem to understand the question of if Resident #3 was on EBP. The ADON (Assistant Director of Nursing) was nearby and tried to translate to the RN but was unable to do so successfully. When the RN was asked if she provides trach care for Resident #3, the nurse again tried using her to translate and asked ADON for assistance. When ADON asked the RN if she had ever provided trach care for Resident #3, she said no, that is respiratory. When asked if she ever wears PPE when providing PEG tube care for Resident #3, she said she wears gloves and sometimes a mask, but the mask is not mandatory. When asked about a gown, she said no. When asked where gowns are kept, she pointed to the empty caddies on the wall. The ADON intervened and said if gowns are not in the caddy they are in the med storage room, the RN said there were no gowns in the med storage room. The ADON verified there were no gowns in the med storage room and proceeded to the unmarked door to room used for education, the ADON said they keep extra gown in here. Side by side observation was made and ADON verified no gowns were in the unmarked room used for education. 3.) Record review for Resident #5 revealed the resident was originally admitted to the facility on [DATE] with most recent readmission on [DATE] with diagnoses that included in part the following: Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side, Tracheostomy Status, and Paralysis of Vocal Cords and Larynx. Review of the Minimum Data Set for Resident #5 dated 11/02/24 documented 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 #5 revealed an order dated 12/26/24 for trach - may suction and lavages resident via trach every shift for trach suction. During an interview conducted on 01/02/25 at 1:05 PM with the wife of Resident #5 who stated she is in the facility for 3-5 hours 5 days a week and other family members come in at various days/times to check on her husband including her son who is a Respiratory Therapist. When asked if the staff provide trach care and suctioning, she said they do but recently the respiratory therapist no longer provide the care, the nurses do, and she feels they do not feel completely comfortable doing the respiratory care. She said she is fully aware of what to look for regarding her husband's trach as her son the respiratory therapist taught her. When asked if staff performing trach care for her husband wear Personal Protective Equipment such as gown, gloves and mask, she said she can only speak to when she is here to see them and no they do not. They always use gloves, but some do not wear mask or gown. On 01/02/25 at 4:15 PM, an observation was made of trach suctioning for Resident #5 performed by 105372 Page 8 of 9 105372 01/02/2025 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 Staff D, Licensed Practical Nurse (LPN). The LPN applied surgical mask and gown, entered room, performed hand washing, applied gloves, pulled back privacy curtain that was dragging on the floor (approximately 2 feet of the privacy curtain not hanging from ceiling). She checked the resident's oxygen saturation with pulse oximeter was 97%. Resident has closed suction set up, good technique with suctioning, however the LPN's surgical mask was below her nose during the suctioning. Residents Affected - Some During an interview conducted on 01/02/25 at 4:30 PM with Staff D, Licensed Practical Nurse (LPN) who stated she has worked at the facility for 1 year. When asked if she always wears her surgical mask below her nose, she stated no, it fell down, and she should have pinched it so it would stay in place. When asked if she had received training for trach care and suctioning, she said yes they all had to do training with the respiratory therapist and return demonstration on a dummy in the classroom setting. When asked if she feels comfortable doing the trach care and suctioning, she said she feels good about doing it. 105372 Page 9 of 9