Health inspection·June 15, 2023

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Review of Resident #121's medical record documented the resident was admitted on [DATE] with diagnoses to include aftercare following joint replacement. Residents Affected - Few Review of the physician's order dated 5/23/23 read, Pt. [patient] to discharge home on 5/26/23 patient declined home health but therapy wants to discharge w/front [with] wheel walker. Review of the IDT [Interdisciplinary Team] Resident Planned Discharge summary dated [DATE] read, 4. Attitude about discharge: Happy to be going home. Review of the MDS dated [DATE] doucmented under Section A2100 Discharge Status, 3. Acute hospital. During an interview on 6/14/2023 at 8:39AM the MDS Coordinator stated, [Resident #121's name] was sent home not to the hospital. It was a miscoding error. [Resident #38's name] did use oxygen during the look back of the MDS I was not checking the oxygen vital summary section, the MDS for the oxygen section is not accurate. Review of policy and procedure titled, Resident Assessment Instruments (RAI) last review date 1/25/2023 documented, Policy: It is the policy of the facility to adhere to the following procedures related to the proper documentation and utilization of a resident's Minimum Data Set (MDS) to ensure a comprehensive and accurate assessment of residents will be completed in the format and in accordance with time frames assessment system will provide a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacities and assist staff to identify health problems for care plan development. Based on observation, interview and record review, the facility failed to ensure the assessment accurately reflects the resident's status for 2 of 3 residents, Residents #38 and #121. Findings include: 1) Review of Resident #38 physician's order dated 2/23/2023 documented, oxygen at 2 liters/min [2 liters per minute] via nasal cannula for sob [shortness of breath] as needed. Review of Resident #38's Oxygen Sats [saturation] Summary documented, Oxygen via nasal cannula on 5/26/2023, 5/23/2023, 5/22/2023, 5/19/2023, 5/18/2023, and 5/15/2023. Review of Resident #38's MDS (Minimum Data Set) Annual dated 5/27/2023 documented, Section O Page 1 of 10 106084 106084 06/15/2023 Avante at Ocala, Inc 2021 SW 1st Ave Ocala, FL 34474

F 0641 Special Treatment procedures, and programs. 2. While a Resident. Oxygen. No. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 106084 Page 2 of 10 106084 06/15/2023 Avante at Ocala, Inc 2021 SW 1st Ave Ocala, FL 34474

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident who was diagnosed with a serious mental illness received re-admission screening and resident review (PASARR) to ensure the resident receives care and services in the most appropriate setting for 1 of 3 residents, Resident #23 for PASARR. Findings include: Review of Resident #23's admission record documented Resident #23 was admitted on [DATE] with a diagnosis of paranoid schizophrenia on 1/26/2023. Review of Resident #23's Quarterly MDS (Minimum Data Set) dated 3/28/2023 documented, Section I, subcategory 1600, of the MDS indicates an active diagnosis of Paranoid Schizophrenia. Review of Resident #23's medical record revealed no level II preadmission screening and resident reviewed (PASARR) was in the medical record. Review of Resident #23's (Name of the Psychiatry Provider Group) Psychiatry Subsequent Note dated 12/15/2023 documented, Chief Complaint: Patient reported hallucinations and delusions. Reason for today's encounter: Today, I saw patient as it was reported to me that patient is unstable requiring psychiatric assessment. History of present illness: Patient was seen today for staff reports that he has been actively hallucination [sic] and delusional. Plan of action: I decided to increase Haldol from 5 mg daily to 5 mg bid [twice a day] for hallucinations/delusions. During an interview on 6/14/2023 at 3:15PM the Director of Nursing stated, [Resident #23's name] should have had a second assessment done once he was diagnoses with Paranoid Schizophrenia. Review of the policy and procedure titled, Coordination-Pre-admission Screening and Resident Review (PASRR) Program last review dated 1/25/2023 documented, 2. Coordination includes: b. Referring all level II residents and all residents with newly evident or possible mental disorder, intellectual disability, or related condition for level II resident review upon a significant change in status assessment. 106084 Page 3 of 10 106084 06/15/2023 Avante at Ocala, Inc 2021 SW 1st Ave Ocala, FL 34474

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** 2) Resident #92 was admitted to the facility on [DATE] with diagnosis to include falls, muscle weakness, and difficulty walking. Residents Affected - Few Review of Resident #92's physician orders dated 6/5/2023 read: Ace [all cotton elastic] wrap right wrist and right ankle two times a day for joint pain. Apply to right wrist and right ankle daily. Apply in am [morning] remove at hs [hour of sleep]. An observation on 6/12/2023 at 10:20 AM of Resident #92 showed the resident did not have an ace wrap on his right wrist or on his right ankle. An observation on 6/13/2023 at 9:20 AM of Resident #92 showed the resident did not have an ace wrap on his right wrist or on his right ankle. During an interview on 6/13/2023 at 9:20 AM Resident #92 stated, I've asked for the ace wraps to be applied but they won't do it. An observation on 6/13/2023 at 12:00 PM of Resident #92 showed the resident did not have an ace wrap on his right wrist or on his right ankle. (Photographic evidence obtained). During an interview on 6/13/2023 at 1:20 PM Staff A, License Practical Nurse (LPN) stated, [Resident #92's name] is supposed to have an ace wrap on his wrist and ankle. He asked for them last week, but I do not know where to get them from. I did not apply his ace wraps last week or this week. During an interview on 6/14/2023 at 1:20 PM Staff B, LPN/Unit Manager stated, The resident should have an ace wrap on his right wrist and right ankle. During an interview on 6/14/2023 at 2:22 PM the Director of Nursing stated, Physician orders need to be followed. Based on observation, interview, and record review the facility failed to provide care and services for central venous access devices in accordance with professional standards of practice for 1 of 3 residents, Resident #174, and for treatment and care of contractures for 1 of 3 residents, Residents #92. Findings include: 1) During an observation on 6/12/2023 at 11:30 AM Resident #174 was lying in bed with a single lumen midline covered with a transparent dressing dated 6/4/2023. During an observation on 6/13/2023 at 8:45 AM Resident #174 was lying in bed with a single lumen midline covered with a transparent dressing dated 6/4/2023. During an observation on 6/14/2023 at 8:10 AM Resident #174 was lying in bed with a single lumen Midline covered with a transparent dressing dated 6/4/2023. During an interview on 6/14/2023 at 8:14AM with Staff C, Licensed Practical Nurse (LPN) stated, I 106084 Page 4 of 10 106084 06/15/2023 Avante at Ocala, Inc 2021 SW 1st Ave Ocala, FL 34474

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few just flushed the line. The dressing is dated 6/4/2023, midline dressing should be changed every seven days, the dressing should have been changed on 6/11/2023. During an interview on 6/14/2023 at 8:21AM the Director of Nursing stated, Midline dressings should be changed every week. We do not have a policy to change the midline dressings on admission we change it every week. Review of Resident #174's admission record documented an admission date of 6/8/2023 with diagnoses to include sepsis, disorder of urinary system, obstructive and reflux uropathy, hemiplegia and hemiparesis, cerebral infraction, chronic pulmonary embolism, type 2 diabetes, morbid obesity, and acute respiratory failure with hypoxia. Review of Resident #174's physician orders dated 6/8/2023 documented, Mid Line: Change Dressing to insertion site RUE [Right upper extremity] every 7 days and PRN [as needed] using sterile technique every night shift every Wed. Review of Resident #174's 3008 (medical certification for Medicaid long-term care services and patient transfer form) dated 6/8/2023 documented, V. Treatment Devices: Midline 5/28/2023. Review of the policy and procedure titled, 4.3 Short Peripheral Intravenous Catheter (PIVC) Dressing Change last review date of 1/25/2023 documented, Guidance: 1. Transparent dressings are changed with each site rotation every seven days, or sooner if the integrity of the dressing is compromised (wet, loose, or soiled). 106084 Page 5 of 10 106084 06/15/2023 Avante at Ocala, Inc 2021 SW 1st Ave Ocala, FL 34474

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) Review of Resident #95's medical record documented the resident was admitted [DATE] with diagnosis to include atrial fibrillation (irregular heartbeat), congestive heart failure, pleural effusions (fluid in lungs), pneumonia, anxiety disorder, acute and chronic respiratory failure, and non-rheumatic aortic stenosis (narrowing of the aorta). Residents Affected - Few Review of physician orders for Resident #95 dated 3/7/2023 read, Ipratropium albuterol inhalation solution .5-2.5(3) MG/ 3 ML (Ipratropium - Albuterol) 1 unit inhale orally every 8 hours for SOB/Congestion [shortness of breath]. An observation on 06/12/23 at 12:25 PM of Resident #95's nebulizer mask showed the mask was lying on the floor in the corner beside the bed and the bedside table. There was no date on the tubing to indicate when the nebulizer tubing was changed. (Photographic evidence obtained). An observation on 6/13/2023 at 2:00 PM of Resident #95's nebulizer mask showed the mask was lying on the floor in the corner beside the bed and the bedside table. There was no date on the tubing to indicate when the nebulizer tubing was changed. During an interview on 6/13/2023 at 3:00 Staff B, License Practical Nurse/Unit Manager stated, The nebulizer mask should never be lying on the floor and the tubing should be dated. All nebulizer tubing is to be changed weekly and tubing is to be dated at that time. During an interview on 6/13/2023 at 3:45 PM the Director of Nursing stated, Tubing is to be changed out every Saturday night and dated. The nebulizer [mask] and tubing should not be lying on the floor and if they are then they are to be thrown away and replaced. Based on observation, interview, and record review, the facility failed to ensure residents received respiratory care services consistent with professional standards of practice for 2 of 4 residents, Residents #84 and #95. Findings include: 1) During an observation on 6/13/2023 at 8:19 AM Resident #84 was lying in bed and had a nasal cannula and tubing lying on the floor by the resident's shoe. The tubing was dated 6/5/2023. (Photographic evidence obtained). During an observation on 6/13/2023 at 9:30 AM Resident #84 was lying in bed with oxygen being administer via nasal cannula at 3.5 liters per minute. The oxygen tubing was dated 6/5/2023. During an interview on 6/13/2023 at 4:10 PM Staff D, License Practical Nurse stated, Oxygen is being administer close to 4 liters I will adjust it a little. The oxygen tubing is dated 6/5/2023 it should have been changed. During an interview on 6/13/2023 at 4:25 PM Director of Nursing stated, The nasal cannula and tubing should have been replaced once the staff found it on the floor. Staff should be checking the oxygen rate every shift. The oxygen [tubing] should have been changed this past Saturday [6/10/2023]. 106084 Page 6 of 10 106084 06/15/2023 Avante at Ocala, Inc 2021 SW 1st Ave Ocala, FL 34474

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #84's admission record documented the resident was admitted on [DATE] with diagnoses to include acute respiratory failure with hypoxia, chronic kidney disease, pleural effusion, and essential hypertension. Review of Resident #84's physician order dated 5/17/2023 documented, Change oxygen set up and bag weekly and as needed every night shift every Saturday for infection control place in labeled O2 [oxygen] bag and tie to handle of O2 concentrator. 106084 Page 7 of 10 106084 06/15/2023 Avante at Ocala, Inc 2021 SW 1st Ave Ocala, FL 34474

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, record review, and interview the facility failed to ensure all drugs and biologicals were stored in locked compartments to permit only authorized personnel to have access for 1 of 3 hallways, the South Unit. Findings include: 1) During an observation on 6/12/23 at 10:30 AM in Resident #8's room there was a tube of Mupirocin Ointment (a medicated ointment used to treat certain skin infections) on the bedside table. (Photographic evidence obtained). During an observation on 6/13/23 at 11:30 AM in Resident #8's room there was a tube of Mupirocin Ointment on the bedside table. During an observation on 6/14/23 at 10:20 AM in Resident #8's room there was a tube of Mupirocin Ointment on the bedside table. Review of the physicians' orders did not have an order for Resident #8 for Mupirocin Ointment or an order for Resident #8 to have medications at bedside. During an interview on 6/12/23 at 10:28 AM Resident #8 stated, That is my cream for my skin sore. I use it anytime my sore opens up. During an Interview on 6/14/23 at 10:28 AM the Director of Nursing stated, [Resident #8's name] is not ordered to have that medication [Mupirocin Ointment] and [Resident #8's name] is not allowed to have medications at bedside. My expectation for the nurses is to make sure that there are no medications at the patients' bedside. Review of the policy and procedure titled, 5.3 Storage and Expiration Dating of Medications, Biologics with a revision date of 07/21/22 read, 13. Bedside Medication Storage: 13.1 Facility should not administer/provide bedside medications or biologicals without a Physician/Prescriber order and approval by the Interdisciplinary Care Team and Facility administration. 2) During an observation on 6/12/2023 at 9:39 AM in Resident #14's room, the resident was lying in bed and there was an ampule of Albuterol on the dresser next to the nebulizer machine. (Photographic evidence obtained). During an interview on 6/12/2023 at 9:39 AM Resident #14 stated, That is [ampule of Albuterol] for my breathing treatment, the nurse will give me the treatment. During an interview on 6/14/2023 at 10:35 AM the Director of Nursing stated, I do not see an order for [Resident #14's name] to self-administer medication. 3) During an observation on 6/12/2023 at 9:46 AM Resident #90 was sitting at the edge of her bed. A Budesonide-Formoterol Fumarate inhaler was lying on top of the bedside table. (Photographic evidence obtained). 106084 Page 8 of 10 106084 06/15/2023 Avante at Ocala, Inc 2021 SW 1st Ave Ocala, FL 34474

F 0761 Level of Harm - Minimal harm or potential for actual harm During an interview on 6/12/2023 at 9:46 AM Resident #90 stated, The nurse left it [inhaler] and forgot to pick it up. During an interview on 6/14/2023 at 10:33 AM the Director of Nursing stated, [Resident #90's name] has no orders for self-administration of medication. Residents Affected - Few 4) During an observation on 6/12/2023 at 9:55 AM in Resident #84's room, the resident was lying in bed. On top of the dresser was a syringe containing normal saline. (Photographic evidence obtained). During an interview on 6/14/2023 at 10:36 AM with the Director of Nursing stated, [Resident #84 name] had an IV [intravenous] catheter for hydration because she was not eating but no longer has the IV. 5) During an observation on 6/12/2023 at 9:59 AM Resident #88 was lying in bed watching television. On top of the dresser there were three bottles of multivitamins, one bottle of vitamin C, one bottle of calcium plus vitamin D3, one bottle of Lubricant eye drops, and one tube of Mentholatum ointment. (Photographic evidence obtained). During an interview on 6/12/2023 at 9:59 AM Resident #88 stated, I drink my multivitamins by myself every day. During an interview on 6/14/2023 at 10:37 AM the Director of Nursing stated, I thought she had orders to self-administer but I do not see an order for self-administration of medications for [Resident #88's name]. 6) During an observation on 6/12/2023 at 10:06AM Resident #57 was lying in bed. Three small packages of A&D (vitamin A and D) ointment and one bottle of Nystatin powder (treats fungal or yeast infections of the skin) were on top of the dresser. (Photographic evidence obtained). During an interview on 6/14/2023 at 10:32 AM the Director of Nursing stated, I do not see an order for [Resident #57's name] to self-administer medication. 7) During an observation on 6/12/2023 at 10:09 AM Resident #36 was lying in bed. A bottle of Acetic Acid 0.25% Solution (used as a constant or intermittent bladder rinse to help prevent the growth and proliferation of susceptible urinary pathogens) was on top of Resident #36's dresser. (Photographic evidence obtained). During an interview on 6/12/2023 at 10:09 AM Resident #36 stated, The nurses use the medication [Acetic acid 0.25% Solution] to flush my catheter twice a day. During an interview on 6/14/2023 at 10:33 AM the Director of Nursing stated, I do not see an order for [Resident #36's name] to self-administer medication. 8) During an observation on 6/12/2023 at 10:30 AM Resident #106 was lying in bed, on top of the dresser there were two ampules of normal saline and a bottle of Nystatin powder. (Photographic evidence obtained). During an interview on 6/12/2023 at 10:30 AM Resident #106 stated, The nurses give me my medication 106084 Page 9 of 10 106084 06/15/2023 Avante at Ocala, Inc 2021 SW 1st Ave Ocala, FL 34474

F 0761 and perform my wound care. Level of Harm - Minimal harm or potential for actual harm During an interview on 6/14/2023 at 10:34 AM the Director of Nursing stated, I do not see an order for [Resident #106's name] to self-administer medication. The residents need to have a self-administration assessment, the nurse needs to call the physician and get an order, provide a lock box or lock for the top drawer, and the nurse needs to observe that the resident is actually able to self-administer the medication. Residents Affected - Few 106084 Page 10 of 10