Health inspection·July 29, 2021

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 and interview, the facility failed to provide nail care for 1 of 5 dependent residents reviewed for Activities of Daily Living (ADL) care of a total sample of 34 residents, (#442). Residents Affected - Few Findings: Resident #442 was admitted to the facility on [DATE]. Her diagnoses included displaced fracture of left femur, generalized weakness, dementia, and diabetes type II. The Medicare 5 days Minimum Data Set (MDS) assessment with assessment reference date (ARD) 7/15/21, showed the resident's Brief Interview of Mental Status (BIMS) score was 03 out of 15 which indicated severe cognitive impairment. The assessment showed the resident required extensive assistance for dressing, and personal hygiene. Observations on 07/26/21 at 12:05 PM, on 7/27/21 at 11:06 AM and on 7/28/21 at 11:22 AM, showed resident #442's fingernails of bilateral hands untrimmed, with a dark substance underneath the nails. The resident could not recall when her nails were last trimmed. She said they could do with some cutting. On 07/27/21 at 4:49 PM, Certified Nursing Assistant (CNA) A stated nail care was done weekly. She explained if the resident was diabetic, CNAs would not trim/cut nails, but should have cleaned the nails weekly as needed. On 07/28/21 at 12:20 PM, resident #442's fingernails were observed with the South Wing Unit Manager (UM). She acknowledged the resident's long and dirty fingernails and said nail care should be done by the clinical staff. She added if the resident refused, the refusal should be documented. She verbalized she had no knowledge of the resident refusing care. The resident's care plan for ADL initiated on 7/09/21 indicated resident #442 needs included extensive assistance with dressing, toileting, personal hygiene, and bathing. The care plan goal read, will receive the amount of necessary ADL assistance to improve/maintain quality of life. Interventions included: requires partial/moderate assistance from staff (more than half) with personal hygiene. Documentation on the resident's Visual/Bedside [NAME] Report read, Keep fingernails short. The facility's policy, Activities of Daily Living (ADLS) Maintain Abilities issued and revised 3/02/19 read, A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good .grooming, and personal and oral hygiene. Page 1 of 5 105671 105671 07/29/2021 Avante at Melbourne Inc 1420 South Oak Street Melbourne, FL 32901

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, interview and record review, the facility failed to ensure oxygen (O2) therapy was administered as per physician orders for 1 of 3 residents and failed to obtain a physician's order for 1 of 3 residents reviewed for oxygen in a total sample of 34 residents, (#441 & #5). Residents Affected - Few Findings: 1. Resident #441 was admitted to the facility on [DATE] with diagnoses of Respiratory Syncytial Virus (RSV), diabetes type II, and acute respiratory failure. The Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (3008) dated 7/23/21, showed the resident was on oxygen 3 Liters (L) continuous. Physician orders dated 7/23/21 included oxygen (O2) continuous at 3 liters per minute (LPM) via nasal cannula (N/C) for acute respiratory failure. Observation on 7/27/21 at 11:10 AM, showed resident #441 received O2 via N/C at 4 LPM. The resident could not say what his O2 rate should be. On 07/27/21 at 4:18 PM, Registered Nurse (RN) B stated resident #441 had diagnoses of RSV, and respiratory failure, and was receiving O2 at 3 LPM via N/C. The resident's physician's order was reviewed with RN B, and she stated the order was for O2 at 3 LPM. On 07/27/21 at 4:24 PM, the resident's O2 settings was observed with RN B. RN B acknowledged the resident's O2 was set at 4 LPM. RN B stated that after she received report from the off going nurse, she reviewed the resident's orders, checked the O2 setting and monitored the resident's O2 saturation. RN B said, I cannot give a good answer as to why the resident's O2 setting was at 4 LPM instead of 3 LPM as per the physician's order. On 07/27/21 at 5:40 PM, and on 7/28/21 at 9:47 AM, the Director of Nursing (DON) stated oxygen therapy training was completed by all nurses using computer-based training on hire and was also included on the annual education calendar. She said staff were educated to follow physician's orders. On 07/28/21 at 11:42 AM, the South Wing UM stated she was aware of the discrepancy in oxygen administration for resident #441. She stated the electronic physician's orders were on the medication carts, and the expectation was that nurses reviewed the orders and ensured the orders were being followed. The resident's baseline care plan, Has a respiratory condition/concern r/t RSV and respiratory failure was created on 7/23/21 with revision on 7/27/21. The Goal was, will make use of oxygen nasal cannula as directed with no complications through the next review date. The interventions included to, Administer oxygen as per MD (Medical Doctor) orders. The facility's policy, Oxygen Administration issued and revised 3/29/2020 read, Oxygen is administered under orders of a physician. 2. Resident #5 was readmitted from an acute care hospital on 4/01/21 with diagnoses that included 105671 Page 2 of 5 105671 07/29/2021 Avante at Melbourne Inc 1420 South Oak Street Melbourne, FL 32901

F 0695 Chronic Obstructive Pulmonary Disease (COPD), pneumonia and Corona Virus Disease 2019. Level of Harm - Minimal harm or potential for actual harm The admission Plan of Care form dated 4/01/21 revealed resident #5 was on continuous oxygen via nasal cannula. The form noted the resident's oxygen saturation level was 93%. Residents Affected - Few Oxygen saturation refers to the amount of oxygen that is in the bloodstream. The normal range for adults is 94 to 99 percent. (Retrieved on 8/1/21 from www.lunginstitute.com). The Minimum Data Set (MDS) annual assessment dated [DATE] and MDS quarterly assessment dated [DATE] revealed resident #5 used oxygen. The annual assessment noted resident #5 did not reject evaluation or care that was necessary to achieve his goals for health and well-being. A care plan for use of oxygen at night related to COPD included a goal for the resident to have no signs/symptoms of poor oxygen absorption. The interventions included monitoring for signs and symptoms of respiratory distress and reporting decreased oxygen level to the physician. A review of the resident's medical record revealed there were no physician's orders for oxygen administration or monitoring the resident's oxygen saturation level. Review of the Rapid Respiratory Evaluation form revealed resident #5's oxygen saturation level was last obtained on 7/4/21. The form indicated resident #5 required oxygen therapy by nasal cannula intermittently or PRN. On 7/26/21 at 10:04 AM, resident #5 was in bed with oxygen tubing noted on the bed beside him. An oxygen concentrator next to resident #5 bed was flowing at 1.5 liters per minute (LPM). On 7/27/21 at 9:09 AM, resident #5 indicated he used oxygen only during the night. The oxygen concentrator was on at 2 LPM and the oxygen tubing was again on the bed next to the resident. On 7/27/21 at 4:31 PM and 5:32 PM, Registered Nurse (RN) E explained that residents who required oxygen therapy were assessed by monitoring oxygen saturation levels, lung sounds, respirations and equipment. RN E indicated resident #5 used oxygen at night. RN E stated she obtained oxygen saturation and verified the oxygen concentrator setting during her shift and documented it on the Medication Administration Record. RN E reviewed the resident's medical record but could not find any orders for oxygen administration. RN E said, I do not see the oxygen order. I don't know why. On 7/27/21 at 5:45 PM, the North Wing Unit Manager (UM) indicated resident #5 should not receive oxygen without a physician's order. The UM reviewed the admission Plan of Care form, the Rapid Respiratory Evaluation, and the physician's orders. He explained there were orders to change the oxygen tubing and humidifier but no order to administer oxygen. The UM acknowledged the last oxygen saturation level documented was 92% on 7/4/21. The UM indicated he did not know how often the oxygen saturation level was to be checked for residents who received oxygen therapy or had a diagnosis of COPD. He explained that oxygen saturation levels were checked, normally every shift. On 7/27/21 at 6:05 PM, the Director of Nursing (DON), explained orders were required for oxygen administration. The DON stated it was not appropriate for a resident with diagnosis of COPD who received oxygen therapy not to have oxygen saturation level checked for 23 days. On 7/28/21 at 9:24 AM, the MDS RN explained she used the physician's orders to answer the oxygen 105671 Page 3 of 5 105671 07/29/2021 Avante at Melbourne Inc 1420 South Oak Street Melbourne, FL 32901

F 0695 Level of Harm - Minimal harm or potential for actual harm therapy question in Section O of the MDS titled, Special Treatments, Procedures, and Programs. The MDS RN acknowledged she completed Section O on both the annual and quarterly assessments that identified resident #5 used oxygen. The MDS RN confirmed there was no order in the medical record for oxygen therapy. She stated she did not know how she missed it. The MDS RN said, I know he uses oxygen, I have known him for a lot of years. I know resident #5 uses it at night, or whenever he gets short of breath. Residents Affected - Few A review of the facility Oxygen Administration policy dated 3/29/20 read, Oxygen is administered to residents who need it, consistent with professional standards of practice . It also included, Oxygen is administered under orders of a physician, except in the case of an emergency. 105671 Page 4 of 5 105671 07/29/2021 Avante at Melbourne Inc 1420 South Oak Street Melbourne, FL 32901

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 interview and record review, the facility failed to ensure the Medication Administration Record (MAR) was accurately completed for 1 of 5 residents reviewed for unnecessary medications of a total of 34 sampled residents, (#10). Findings: Resident #10 was admitted to the facility on [DATE]. Her diagnoses included Chronic Obstructive Pulmonary Disease (COPD), bipolar disorder, heart failure, anxiety disorder, major depressive disorder, and aftercare following joint replacement. Physician orders showed the resident's medications included Lamotrigine 100 milligram (mg) twice daily (BID) for Bipolar, Gabapentin 300 mg BID, Morphine Sulfate 15 mg three times daily (TID) for pain, Baclofen 5 mg TID for pain, and Mucinex 600 mg BID for cough/congestion inhale every 8 hours as needed for shortness of breath, Senna 8.6 mg BID for constipation. Record review of the resident's MAR for July 2021 showed blank spaces on 7/11/21 for the resident's 9 PM medications listed above. There was no documentation/signature/ code, to indicate the medications were given. On 07/29/21 at 11:05 AM, the Director of Nursing (DON) stated that when medications were administered, nurses signed for the administration of medications on the MAR, and if the medication was not given, a code should be entered indicating the reason the medication was not given. The resident's MAR for July 2021 was reviewed with the DON. She acknowledged the blank spaces on 7/11/21 at 9:00 PM for the medications mentioned above. The DON said blank spaces were, not acceptable On 07/29/21 at 11:57 AM, Registered Nurse (RN) C stated she worked on the 3 PM-11 PM shift on 7/11/21. She stated that it was awhile ago, and she did not recall what happened. RN C stated the only reason she would not give medications, would be if the resident refused, was asleep or was not in the facility. RN C stated she always documented medications given and if the medications were not given, a code would be documented, to indicate the reason. RN C stated I really don't know why it is showing up blank. She verbalized that blank spaces on the MAR were not acceptable. On 07/29/21 at 12:16 PM, Licensed Practical Nurse (LPN) D stated when medications were administered, it would be signed off on the MAR. She explained if medications were not given, or the resident refused, a code should be entered, and a progress note documented. LPN D stated that a blank space indicated the resident did not receive the medications, and said, the MAR should not be left blank. The resident's MAR was reviewed with LPN D, who confirmed the blank spaces on 7/11/21 for the 9 PM medications. On 07/29/21 at 12:23 PM, the South Wing UM stated the expectation was the MAR would be completed, with no blank spaces. If the medications were not given, a code should be entered indicating the reason, and/or action taken. The resident's MAR for July 2021 was reviewed with the UM. She verified the blank spaces and said the MAR should not have blanks. 105671 Page 5 of 5