Health inspection·March 4, 2021

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and interviews, the facility failed to develop a comprehensive person-centered urostomy care plan for one (Resident #74) of 28 residents whose care plans were reviewed from a total sample of 45 residents. The findings include: An observation and interview was conducted with Resident #74 on 3/1/2021 at 11:32 a.m. in her room. She reported she had a urostomy and the urostomy bags she used were not available when she first came to the facility. This resident used a [NAME] urostomy bag, which had a separate flange and bag. The clinical staff assisted her with applying the appliance. She had to use the one the facility kept in stock which she stated irritated her skin. A record review was conducted for Resident #74, which noted an original admission date of 1/20/21 with a readmission on [DATE]. The Minimum Data Set (MDS) 5-day assessment, dated on 2/11/21, noted under section H that the resident had a urostomy. A review of the updated care plan noted there was no urostomy focus, goal or interventions to guide staff as to the resident's care needs. An interview was conducted with Employee G, Licensed Practical Nurse (LPN)/MDS Coordinator, on 03/03/21 at 1:24 p.m. Employee G was asked to review Resident #74's care plans and indicate if there was a care plan with a focus on Resident #74's urostomy. The LPN confirmed there was no care plan for the urostomy and there should have been. . Page 1 of 8 105617 105617 03/04/2021 Avante Villa at Jacksonville Beach Inc 1504 Seabreeze Ave Jacksonville Beach, FL 32250

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 record review, interviews and a review of the policy and procedure for implanted venous access, the facility failed to provide appropriate treatment and care for a portacath (implanted central line) for one (Resident #74) of a total sample of 45 residents, by not changing the Huber needle in accordance with professional standards of practice. Residents Affected - Few The findings include: An observation and interview was conducted with Resident #74 on 3/1/2021 at 11:32 a.m. in her room. The resident reported a portacath was located in her left upper chest which was observed. She reported it was not being flushed daily, the dressing was not changed as ordered, and no one had changed the Huber needle since she was admitted . She reported having had at least six portacaths and knew a lot about them. A medical record review noted an admission date of 1/20/21, and a readmission date of 2/5/21. The resident's diagnoses included the presence of a cardiac implant. The care plan, updated 2/23/21, included a focus area for a portacath at the left upper chest area with interventions to change the dressing per physician's orders, monitor for patency and change the tubing per order/facility protocol. The medical record was reviewed for documentation verifying the changing of the Huber needle, and no documentation was found to indicate it had been changed since the resident was admitted to the facility. A review of current physician's orders revealed an order dated 2/9/21 for a dressing change every seven days. An interview was conducted with the Director of Nursing (DON), Registered Nurse (RN), at 2:30 p.m. on 3/4/2021. The DON was asked when the portacath Huber needle was changed, and she reported she did not know. A review of the facility's policy and procedure for Implanted Venous Access Ports, revised May 1, 2016, noted under guidance: Non [NAME] needles are changed every 7 days and correspond with dressing changes. An interview was conducted via telephone with the Medical Director on 3/4/21 at 2:10 p.m. He was asked about the frequency of changing the dressing and changing the Huber needle for the portacath. He reported the Huber needle should be changed every seven days with the dressing. He stated the length of dressing changes depended upon physician's orders, but usually every seven days and as needed if soiled. . 105617 Page 2 of 8 105617 03/04/2021 Avante Villa at Jacksonville Beach Inc 1504 Seabreeze Ave Jacksonville Beach, FL 32250

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, clinical record review, and facility policy and procedure review, the facility failed to ensure the accurate and safe provision of narcotic medication to one (Resident #47) of five residents who underwent medication review from a total of 45 residents in the sample. Resident #47 received expired narcotic medication (Norco) on two occasions. The findings include: During an observation of medication administration on [DATE] at 12:00 p.m. with Employee E, Licensed Practical Nurse (LPN), she was asked to pull a random narcotic blister card for an audit of her narcotic count. The card pulled belong to Resident #47. The card contained Norco (narcotic pain reliever) 5-325 mg (milligrams) with a physician's order that read, Give 1 tablet by g-tube (feeding tube) every 4 hours as needed (non acute pain). The card contained six tablets. The reconciliation sheet for this card contained in the narcotic count book showed six tablets remained. Upon inspection, it was noted that the card containing the pills had an expiration date of [DATE]. The reconciliation sheet showed that two doses had been administered after that expiration date. On February 13, 2021 one dose was given at 3:30 p.m., and another dose was given that same day at 9:00 p.m. These doses were signed out by Employee C, Registered Nurse (RN). During an interview with Employee E on [DATE] at 12:05 p.m., she was asked what her practice was if she came across expired medication in a blister card. She stated, I remove it and for this, it's a narcotic, so I am also removing the sign-out sheet, and I will remove the card from the card count too. Then I will lock this in my narcotic drawer and call the DON (Director of Nursing) to come remove it. She was asked when she checked the expiration dates on the medication blister cards to ensure the medication was not expired. She replied that she checked the dates before she administered medication from each card. She stated this was always her practice. During inspection of the [NAME] Wing medication cart (front hall) on [DATE] at 1:45 p.m., Employee C, RN, was asked what she should do if she identified a blister card with expired medication in her narcotic count. She stated, I would pull it from the count and put it's page with it, and lock it in the narcotic drawer on the side until the DON can come down and remove it from the count. She was asked if she checked the expiration date each time before removing a medication from the blister card and administering it to a resident. She stated yes. A review of the facility's policy/procedure titled Storage and Expiration of Medications, Biologicals, Syringes, and Needles (effective [DATE], revised [DATE], [DATE] and [DATE]), revealed that the facility should ensure medications and biologicals that 1. have an expired date on the label; 2. have been retained longer than recommended by the manufacturer or supplier guidelines; or 3. have been contaminated or deteriorated, are stored separately from other medications until destroyed or returned to the pharmacy or supplier. . 105617 Page 3 of 8 105617 03/04/2021 Avante Villa at Jacksonville Beach Inc 1504 Seabreeze Ave Jacksonville Beach, FL 32250

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on staff interviews, clinical record review, and facility policy and procedure review, the facility failed to ensure a gradual dose reduction (GDR) of an antipsychotic medication for one (Resident #18) of five residents whose medication regimens were reviewed, from a total of 45 residents in the sample. The findings include: A review of pharmacy consultation reports revealed that on December 1, 2020, the pharmacist recommended a gradual dose reduction for the medication Quetiapine (antipsychotic) 25 mg (milligrams) to be reduced to 12.5 mg with the end goal of discontinuation, while concurrently monitoring for reemergence of target symptoms. This recommendation was signed by the resident's physician on December 7, 2020 with the response, I accept the recommendation, please implement as written. Further review revealed that on January 14, 2021, the pharmacist gave a repeat recommendation: In a consultation report dated December 1, 2020: Please respond promptly to assure facility compliance with Federal regulations. [Resident #18] was recently admitted with an order for an antipsychotic medication Quetiapine 25 mg for diagnosis requested. Recommendation: Please attempt gradual dose reduction to Quetiapine 12.5 mg with the end goal of discontinuation, while concurrently monitoring for reemergence of target symptoms. This consult report was not signed by the physician. A review of the pharmacist's GDR tracking review revealed: 1/15/2021: GDR tracking reviewed for: Quetiapine (next GDR eval due 2/28/2021) 2/15/2021: GDR tracking reviewed for: Quetiapine (next GDR eval due 2/28/2021) A review of the Medication Administration Records (MARs) for Resident #18 for the months of December 2020, January 2021, February 2021 and March 2021, revealed that the resident received Quetiapine 25 mg daily by mouth for the duration of December, January and February, with the last dose given on March 2, 2021. A review of current physician's orders revealed an order which read, OK to d/c (discontinue) Seroquel (Quetiapine) per resident request, which was dated March 2, 2021. Further review of all physician's orders entered into the resident's electronic medical record revealed the only other order concerning Quetiapine was the initial admission order which read, December 1, 2020: Quetiapine 25 mg by mouth daily. A review of Resident #18's quarterly Minimum Data Set (MDS) assessment, dated February 28, 2021, revealed documentation under the medications section which read, Did resident receive antipsychotic medications since admission/reentry or prior OBRA assessment? Yes (routine basis only) Has a GDR been attempted? No 105617 Page 4 of 8 105617 03/04/2021 Avante Villa at Jacksonville Beach Inc 1504 Seabreeze Ave Jacksonville Beach, FL 32250

F 0758 MD documented GDR as clinically contraindicated? No. Level of Harm - Minimal harm or potential for actual harm A review of the person-centered care plan for Resident #18, with the last revision date of February 24, 2021, revealed: Residents Affected - Few Focus: (Resident #18) uses psychotropic medications r/t (related to) dx (diagnoses) of anxiety, depression, insomnia, and bipolar disorder. Goals: (Resident #18) will have no untreated s/s (signs and symptoms) of psychotropic drug related to complications including movement disorder, discomfort, hypotension, gait disturbance, constipation, or cognitive/behavioral impairment through next review date. Interventions: Administer meds (medications) as ordered, observe for side effects and effectiveness PRN (as needed). Completes AIMS (assessment) as required and PRN. Consult with pharmacy, MD to consider dosage reduction when clinically appropriate at least quarterly. Discuss with MD, family re: ongoing need for medication. Review behaviors/interventions and alternate therapies attempted and their effectiveness per facility policy. Educate the resident/family about risks/benefits and the side effects and/or toxic symptoms. Observe/document/report PRN any adverse reactions of psychotropic medication: unsteady gait, tardive dyskinesia, EPS, frequent falls, refusal to eat, diff swallowing, dry mouth, depression, suicidal ideation, social isolation, blurred vision, fatigue, weight loss, insomnia, n/v (nausea/vomitting), muscle cramps, behavioral symptoms not usual to the person. Refer to psychiatry as ordered. During an interview with the Director of Nursing (DON) on March 3, 2021 at 3:40 p.m., she was asked when the pharmacy made a GDR recommendation, and the physician agreed with the recommendation, what happened next. She replied, The nurse will take the signed recommendations and transcribe the order. Then the order is implemented. She was asked if the nurse on the unit at the time, caring for the resident, was the nurse who transcribed and implemented the order, or was someone specific responsible for this task, she replied, It's the nurse who is caring for the resident when the order comes in. She was then asked whether there was a specific time frame during which the new order should be transcribed and implemented, and she replied, No, it should just be done when the order is received. . 105617 Page 5 of 8 105617 03/04/2021 Avante Villa at Jacksonville Beach Inc 1504 Seabreeze Ave Jacksonville Beach, FL 32250

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on record review and interviews, the facility failed to administer Keppra (anti-seizure medication) as ordered for one (Resident #74) of five residents whose medications were reviewed, from a total of 45 residents in the sample. Failure to administer anti-seizure medication per the physicians' order can result seizure activity. Residents Affected - Few The findings include: An observation and interview was conducted with Resident #74 on 3/1/21 at 11:32 a.m. in her room. She reported going to the hospital on 2/1/21 with multiple seizures, and she did not believe she was receiving her Keppra as ordered. A medical record review was conducted, which noted an admission date of 1/20/21 and a readmission date of 2/5/2021. The resident's diagnoses included seizures. A physician's order dated 1/21/2021, noted Keppra 1000 mg (milligrams) to be administered twice a day for seizures. The care plan, updated 2/23/21, included a focus area for a diagnosis of seizure disorder. The interventions included: administer medications as ordered by physician, observe for side effects and effectiveness, and document seizures. A review of the nursing notes revealed that on 2/1/21 at 12:50 p.m., a CNA (certified nursing assistant) reported the resident was having seizures. Upon assessment, the resident was noted to have several back to back grand mal seizures. The Physician's Assistant was notifed and an order was received to send the resident to the emergency room for evaluation and a CT scan. (a medical imaging technique) A review of the hospital History and Physical, dated 2/2/2021, noted the resident was at the nursing home, had 13 seizures, and was admitted to the hospital following the seizures. The resident reported her physician's order for taking Keppra 1000 mg twice a day. While in the Emergency Department the patient was loaded with Keppra. A record review of the Medication Administration Record (MAR) for January 2021, revealed Keppra was not signed out as having been administered to Resident #74 on 1/21, 1/29 or 1/30/21. The resident was hospitalized with seizures on 2/1/2021. The MAR for February 2021 was reviewed and revealed Keppra was not signed out as having been administered on 2/1 (the date of hospitalization, left facility after medication should have been given at 9:00 a.m.), 2/9, 2/14 or 2/26/21. An interview was conducted with Employee C, Registered Nurse (RN), at 1:30 p.m. on 3/4/2021. She stated she reviewed the MAR, pulled the medication, checked off each medication, saved the screen until after the medication was taken, and then it was locked. If a resident refused the medication, there was a space to enter that information, and it populated on the MAR. If there was a blank space where initials should have been documented on the MAR, the medication was not given. An interview was conducted with the facility's Medical Director (MD) at 2:10 p.m. on 3/4/2021. The primary physician for Resident #74 was not available. The MD stated, I tell my patients to not miss one dose of Keppra because they could have a seizure, and I encourage them to take it as ordered. They should not be missing any doses of Keppra. . 105617 Page 6 of 8 105617 03/04/2021 Avante Villa at Jacksonville Beach Inc 1504 Seabreeze Ave Jacksonville Beach, FL 32250

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. Based on observation, medical record review and interviews, the facility failed to ensure accuracy of the medical record by 1) Signing off a treatment as having been completed when it was not completed, and 2) Failing to sign out ordered medications as having been administered for one (Resident #74) of five residents whose medications and treatments were reviewed from a total of 45 residents in the sample. The findings include: An observation and interview was conducted with Resident #74 on 3/1/2021 at 11:32 a.m. in her room. She reported that a portacath was located in her left upper chest, which was observed. She stated the dressing was not being changed as ordered. An observation of the portacath on her left chest revealed a dressing dated 2/24/2021. Resident #74 reported having had at least six portacaths and stated she knew a lot about them. A medical record review was conducted, which noted an admission date of 1/20/21 and a readmission date of 2/5/2021. Her diagnoses included the presence of a cardiac implant. The care plan, updated on 2/23/21, included a focus area for a portacath to the left upper chest area with interventions including: change the dressing per physician's orders, monitor for patency and change the tubing per order/facility protocal. A review of the current physician's orders revealed on order, dated 2/9/21, for a dressing change every seven days. A review of the Medication Administration Record (MAR) for January 2021 and February 2021, revealed multiple blanks where medications were not signed out as having been administered. They included the following: Atorvastatin 40 mg (milligrams) at bedtime, not initialed as having been given on 1/21, 1/28, 1/29, 1/30, 2/5, 2/9, 2/14 or 2/26/21 Colace 100 mg, 2 capsules at bedtime orally, not initialed as having been given on 1/28, 1/29, 1/30, 2/9, 2/13, 2/14 or 2/26/21 Trazodone 100 mg, 2 tablets at bedtime orally, not initialed as having been given on 1/21, 1/28, 1/29, 1/30, 2/9, 2/12, 2/14 or 2/21/21 Sertaline HCL (hydrochloride) 100 mg every day orally, not initaled as having been given on 2/9, 2/14 or 2/26/21 A review of the March 2021 Treatment Administration Record (TAR), revealed a dressing change was signed off as having been completed by Employee F, Licensed Practical Nurse (LPN), on 3/2/21. An interview was conducted with the resident in her room on 3/3/21 at 9:07 a.m. She reported the dressing was not changed. The dressing was observed at the time of the interview and it was dated 2/24/21. Employee I, Registered Nurse (RN), was asked to check the portacath dressing for Resident #74 on 3/3/21 at 12:55 p.m. The RN applied gloves and observed the portacath dressing. She reported it was changed and dated 2/24/21, and the order was to change the dressing every seven days. The RN went to the medication cart and pulled up the TAR. She confirmed the dressing was signed off as having been 105617 Page 7 of 8 105617 03/04/2021 Avante Villa at Jacksonville Beach Inc 1504 Seabreeze Ave Jacksonville Beach, FL 32250

F 0842 changed yesterday (3/2/21) by Employee F. Level of Harm - Minimal harm or potential for actual harm An interview was conducted with the Director of Nursing (DON) on 3/4/21 at 10:10 a.m. concerning the portacath dressing that was signed off on 3/2/21 for Resident #74, but was not done. She reported she spoke to the employee about signing off the dressing for the portacath when it had not been completed. The DON stated, [Employee F] was going in to do it, and the resident had gone out of her room. Education is being provided for not signing off until the task is completed for her. She is coming in today to sign the education piece and answer any questions you may have. Residents Affected - Few An interview was conducted with Employee C, Registered Nurse (RN), at 1:30 p.m. on 3/4/2021. The RN reported she reviewed the MAR, pulled medication, checked off each medication, and saved the computer screen until after the medication was taken, and then it was locked. If a resident refused the medication, there was a space for that information, and it populated on the MAR. If there was a blank space on the MAR where initials were supposed to be entered when a medication or treatment was administered/provided, the medication/treatment was not provided. An interview was conducted with Employee F, LPN, on 3/4/21 at 3:34 p.m. concerning the portacath dressing. The LPN reported, I signed off on the dressing, but she (Resident #74) was not in the room. I thought I would come back, but she never returned to the room. She reported she received new training instructing her not to sign off treatments until they had been completed. . 105617 Page 8 of 8