Health inspection·December 22, 2025

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observations, interviews, and record review, the facility failed to ensure that professional standards of practice were adhered to regarding the changing and dating of enteral feeding equipment for five (Residents #1, #15, #17, #18 and #19) of eight residents reviewed for enteral tube feeding (TF). This could result in the residents not receiving appropriate care and/or clinical complications.1. On 12/22/2025 at 10:00 am, Resident #1 was observed lying in bed with the head of the bed elevated at approximately 30 degrees. Nutren 1.5 enteral feeding was noted to be infusing via g-tube at 60 milliliters (ml)/hour (hr.). The water flush bag was dated on 12/20/2025 at 6:00 am and the enteral feeding bag was undated. (Photographic evidence obtained)Review of Resident #1's medical record revealed an admission date of 5/26/2025. Her diagnoses included Hemiplegia and Hemiparesis following nontraumatic intracerebral hemorrhage affecting right dominant side, Neuromuscular Dysfunction of Bladder, Unspecified Atrial Fibrillation, and Gastrostomy Status.Review of Resident #1's physician's orders revealed free water 180ml/4h to provide 1080 ml of free water with formula and flushes (6/13/2025) and enteral feed two times a day Nutren 1.5ml @ 60ml/hr. x 20 hr. (off 12 am, on 4 am) + 180 ml free water flow q4hr (6/1/2025).2. On 12/22/2025 at 11:30 am, Resident #15 was observed to be lying in bed with the head of the bed elevated at approximately 30 degrees. The resident's water bag for his enteral tubing was undated. (Photographic evidence obtained)Review of Resident #15's medical record revealed an admission date of 10/16/2025. His diagnoses included gastrostomy status, amyotrophic lateral sclerosis, dysphasia, oropharyngeal phase, functional quadriplegia, and major depressive disorder. Review of Resident #15's physician's orders revealed enteral feed order every shift Osmolite 1.5 70 ml/hr. continuous 150 milliliter flush every three hours while pump is on and enteral feed order every shift Osmolite 1.5 start feeding at 0600 infuse at 80 milliliters an hour continuous until 1280 milliliters has been infused flush with 120 milliliters water every two hours while pump is on flushed by syringe 120 milliliters before and after each feed cycle period.3. On 12/22/2025 at 11:40 am, Resident #17 was observed to be lying in bed with the head of the bed elevated at approximately 30 degrees. The resident's water bag for her enteral tubing was undated. (Photographic evidence obtained)Review of Resident #17's medical record revealed an admission date of 5/24/2024. Her diagnoses included hemiplegia and hemiparesis following cerebral infarction, dysphagia, oropharyngeal phase, aphasia, other specified anemias, unspecified severe protein calorie malnutrition, bipolar disorder, other seizures, gastrostomy status, neuromuscular dysfunction of bladder, and gastroesophageal reflux disease.Review of Resident #17's physician's orders revealed enteral feed order two times a day Isosource 1.5 at 55 ml/hr. for 20 hours, flush with 200 milliliters of water every four hours.4. On 12/22/2025 at 11:45 am, Resident #18 was observed to be lying in bed with the head of the bed elevated at approximately 30 degrees. The resident's water bag for her enteral tubing was undated. (Photographic evidence obtained)Review of Resident #18's medical record revealed an admission date of 9/8/2023. Her diagnoses Page 1 of 2 105617 105617 12/22/2025 Avante Villa at Jacksonville Beach Inc 1504 Seabreeze Ave Jacksonville Beach, FL 32250

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some included other Cerebral Infarction due to Occlusion or Stenosis of Small Artery and Anoxic Brain Damage. Review of Resident #18's physician's orders revealed Isosource 1.5 at 60ml/hr. for 20 hours off 10:00 am to 2:00 pm for Activities of Daily Living with/200 milliliters of Free Water Flush every 6 hours.5. On 12/22/2025 at 11:55 am, Resident #19 was observed to be lying in bed with the head of the bed elevated at approximately 30 degrees. The resident's enteral feeding bag was undated. (Photographic evidence obtained)Review of Resident #19's medical record showed to read an admission date of 4/8/2022. The resident's diagnoses included malignant carcinoid tumor of the small intestine, gastrostomy status, hemiplegia and hemiparesis following cerebral infarction, dysphagia, oropharyngeal phase, and gastroesophageal reflux disease. Review of Resident #19's physician's orders revealed enteral feed order every four hours flush with 150 milliliters of water, Enteral feed to order flush G tube with 10 CC's of water before and after bolus feeds, and Enteral feed order two times a day Isosource 1.5 at 50 ml/hr. for 20 hours plus 150 milliliters of free water flow every four hours-on at 2:00 PM off at 10 AM period.During an interview on 12/22/2025 at 10:50 am, Staff A, Licensed Practical Nurse (LPN), stated, The night shift changes out all of the tube feedings, bags and syringes. When asked why there were several tube feedings that were either undated or outdated, LPN stated, Night shift changes those.During an interview on 12/22/2025 at 1:30 pm, Staff B, Registered Nurse (RN), stated, The bags and everything are changed out on the midnight shift.During an interview on 12/22/2025 at 2:15 pm, the DON stated, All the tube feedings, water bags and syringes are changed out by the midnight shift. It should be dated when it is placed. 105617 Page 2 of 2