How many inspection deficiencies does AVANTE AT ORLANDO INC have?

AVANTE AT ORLANDO INC has 21 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

Where is AVANTE AT ORLANDO INC located?

AVANTE AT ORLANDO INC is located in ORLANDO, FL. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does AVANTE AT ORLANDO INC have?

AVANTE AT ORLANDO INC has 118 certified beds.

Who owns AVANTE AT ORLANDO INC?

AVANTE AT ORLANDO INC is a for profit - corporation facility and is part of the AVANTE CENTERS chain.

What questions should families ask when visiting AVANTE AT ORLANDO INC?

Families visiting AVANTE AT ORLANDO INC should ask about daily routines, communication with families, how they handle medical emergencies. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does AVANTE AT ORLANDO INC compare to other nursing homes?

AVANTE AT ORLANDO INC has a 3-star overall rating, which is average compared to other nursing homes in FL. Consider visiting multiple facilities before making a decision.

AVANTE AT ORLANDO INC

Name: AVANTE AT ORLANDO INC
Address: 2000 NORTH SEMORAN BOULEVARD, ORLANDO, FL, 32807, US
Telephone: (407) 671-5400
Rating: 3.0

2000 NORTH SEMORAN BOULEVARD, ORLANDO, FL 32807 · (407) 671-5400

For profit - Corporation 118 Beds AVANTE CENTERS Data: November 2025

Trust Grade

55/100

#317 of 690 in FL

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Last Inspection: October 2021

Over 2 years since last inspection. Current conditions may differ from available data.

Overview

Avante at Orlando Inc has a Trust Grade of C, indicating it is average and in the middle of the pack among nursing homes. They rank #317 out of 690 facilities in Florida, placing them in the top half, and #14 out of 37 in Orange County, meaning only 13 local options perform better. The facility's trend is worsening, with issues increasing from 1 in 2020 to 5 in 2021. Staffing is a notable concern, rated at 0 out of 5 stars, although the turnover rate is exceptionally low at 0%. While there are no fines reported, which is a positive sign, there have been serious incidents, including a failure to prevent a pressure ulcer for one resident and inadequate temperature controls for dishwashing, highlighting both care and procedural weaknesses. Overall, while there are strengths in low fines and a decent rank, the facility faces significant challenges in staffing and quality of care.

Trust Score: C
In Florida: #317/690
Safety Record: Moderate
Inspections: Getting Worse
Staff Stability: Turnover data not reported for this facility.
Penalties: No fines on record. Clean compliance history, better than most Florida facilities.
Skilled Nurses: RN staffing data not reported for this facility.
Violations: 21 deficiencies on record. Higher than average. Multiple issues found across inspections.

★★★☆☆

3.0

Overall Rating

☆☆☆☆☆

0.0

Staff Levels

☆☆☆☆☆

0.0

Care Quality

★★★☆☆

3.0

Inspection Score

↔

Stable

2020: 1 issues

2021: 5 issues

The Good

Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in fire safety.

The Bad

3-Star Overall Rating

Near Florida average (3.2)

Meets federal standards, typical of most facilities

Chain: AVANTE CENTERS

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 21 deficiencies on record

1 actual harm

Oct 2021 5 deficiencies 1 Harm

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Pressure Ulcer Prevention (Tag F0686)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to prevent the development of a new pressure ulcer, and failed to provide care and services to promote healing once it developed for 1 of 2 residents sampled with pressure ulcers in a total sample of 35 residents, (#11). The facility's failure to implement preventative measures consistent with the resident's risk for skin breakdown and failure to implement treatment according to accepted standards of practice resulted in actual harm, development of a Stage III pressure ulcer to the right ear which worsened to a Stage IV pressure ulcer. Findings: Resident #11 was admitted to the facility on [DATE] with diagnoses of strokes, dysphagia, aphasia, pain, diabetes mellitus, and malignant tumor of the colon. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] noted the resident was severely impaired for decision making and was totally dependent on 2 staff for bed mobility, transfers and toileting. The assessment showed he was always incontinent of urine, bowels and had 1 unstageable pressure ulcer upon admission. On 10/25/21 at 10 AM, the South Wing Unit Manager (UM) provided a list of residents with care needs. The list noted resident #11 was on continuous oxygen therapy at 3 liters per minute and received tube feedings. There was no mention of any pressure ulcers. A physician order dated 8/4/21 read, weekly skin observations to be done every Saturday and nurse to perform head to toe skin sweep and complete Weekly Skin observation . The facility's Weekly Skin Observation form dated 8/3/21 noted the resident had a pressure ulcer on the coccyx, at admission. The pressure ulcer was assessed by the wound Advanced Practitioner Registered Nurse (APRN) on 8/4/21 and noted the wound was on the sacrum not the coccyx. The sacral wound measured 2.5 centimeters (cm) in length X 2.5 cm in width X 0.5 cm in depth. The wound was from pressure and the APRN noted the wound was unstageable but not unavoidable. A Weekly Skin Observation form dated 8/13/21 read the resident did not have any new pressure ulcers. On 10/25/21 at 10:33 AM, the resident was in bed on an air mattress with the head of the bed (HOB) elevated at 30 degrees. His head was to the right side and his chin was down towards his chest. His right ear was touching the pillow and there no positioning device to maintain his head at midline. He had oxygen by nasal cannula and did not respond to verbal stimuli. On 10/25/21 at 11:17 AM, the resident's assigned Registered Nurse, (RN) D said the resident had a stage II pressure ulcer on the sacrum that was acquired at the facility. He did not mention any other pressure ulcers. On 10/25/21 at 4:39 PM, the resident was on his right side with his head down, chin touching his chest and the ear touching the pillow. The resident did not have any positioning devices. The oxygen nasal cannula was in place and the resident's eyes were closed. A Nursing Progress Note on 8/19/21 revealed the resident was transferred to the hospital for low oxygen levels. He was re-admitted to the facility on [DATE] and was seen by the wound care APRN on 8/25/21. She noted the unstageable pressure ulcer on the sacrum now measured 1.8 cm x 0.9 cm x 0.2 cm. She also noted no other pressure ulcers upon re-admission. A review of the resident's care plan noted he had an unstageable pressure ulcer on the sacrum that was present on admission caused by prolonged pressure related to impaired bed mobility, incontinence . The approaches included to document any changes in skin integrity and notify licensed nurse of any new open areas, obtain weekly skin checks and notify physician of any changes in skin integrity. A review of the Weekly Skin Observation form noted the resident did not have any weekly skin checks done since he returned from the hospital on 8/21/21 until 9/15/21, indicating more than 3 weeks of weekly skin checks were missed. The evaluation dated 9/15/21 showed the resident had a new pressure ulcer to the right ear at stage III. The resident was seen by the wound care APRN on 9/15/21 and the note documented the resident had a facility acquired stage III pressure ulcer to the right ear that measured 2 cm X 0.5 cm X 0.3.Patient favors his head to the right. Necrotic tissue is noted with moderate drainage. Treatment of this wound: cleanse with wound cleanser and pat dry. Apply honey fiber to wound bed and place non-adhesive foam between the ear and pillow daily . The wound care APRN wrote the right ear pressure ulcer was Unavoidable, but did not provide a rationale as to why the ear pressure ulcer was unavoidable. A note by the wound care APRN dated 9/22/21 showed the right ear pressure ulcer was facility acquired and had worsened to Stage IV.The ear wound is unavoidable since the patient favors his head laying this way and is difficult to offload. Patient has a history of left sided stroke which could contribute to the reason he favors his right side . Contrary to the APRN's note, the resident did not have a foam device to offload his right ear from the pillow. On 10/26/21 at 3:32 PM, the resident was again observed in bed with the head of bed elevated at least 30 degrees. His head was down with his chin towards his chest and towards the right side. His right ear was touching the pillow and there was no foam between the ear and the pillow. The resident's direct care Certified Nursing Assistant, (CNA) F stated the resident, doesn't really get out of bed. The CNA voiced no concerns about the resident's positioning or about the missing foam that was supposed to between his ear and the pillow. A few minutes later, RN D entered the resident's room, checked the oxygen concentrator for flow rate and indicated the CNAs would reposition the resident but made no mention of the foam that was missing between the resident's ear and pillow. On 10/27/21 at 12:45 PM, resident #11's wound treatment was observed with the facility's Wound Care Nurse (WCN), Director of Nursing (DON), wound care APRN and a Physician Assistant. The APRN stated the right ear pressure ulcer was unstageable and measured 1.6 cm X 0.6 cm X 0.2 cm indicating the ulcer had worsened. The APRN explained the facility's therapy staff were working on an offloading device for the ear as the resident favored his right side. On 10/27/21 at 1:37 PM, the residents daughter was at the bedside and stated that after the fourth stroke, her father had become a resident at this facility. She said he had a pressure ulcer on his right ear, He got that here. On 10/27/21 at 4:46 PM, the resident was in bed and had a U shaped pillow around his neck with a foam piece between the neck pillow and his right ear. The resident appeared to be positioned better, as he was midline, and not fixed to his right. Further review of the resident's care plans revealed the care plan had not been updated after the right ear pressure ulcer was discovered. There was no evidence the facility had any specific pressure offloading approaches for the right ear prior to the discovery of the pressure ulcer. The pressure injury care plan was updated to reflect the resident's right ear pressure ulcer, only when the U shaped pillow was started on 10/27/21. On 10/28/21 at 9:49 AM, RN D stated that weekly skin checks were to be completed by the nurses and for resident #11, checks were to be done on the 7 AM to 3 PM shift. He explained weekly skin checks were to be done even if the resident was being seen by the WCN. RN D stated when he first saw resident #11's right ear wound, it was a laceration. He said he put an order for a wound consult and then the Wound Nurse began assessing him. RN D stated the U shaped pillow was just put on him, yesterday, from therapy. At 9:57 AM, the South Wing UM reviewed the weekly skin checks in the electronic medical record and found weekly skin checks dated 8/3/21, 8/13/21 and 9/15/21. She could not explain why there were missing weekly skin checks between 8/13/11 and 9/15/11. She explained if weekly skin checks were missed, the DON and/or the Assistant Director of Nursing (ADON) were responsible to ensure they were completed. On 10/28/21 at 10:25 AM, a meeting was held with the Administrator, DON, WCN and Regional Nurse. The DON explained that Weekly Wound Evaluations were completed by the WCN for residents with pressure ulcers and Weekly Skin Observations were completed by the direct care nurses on all residents including those with pressure ulcers. The DON was presented with Weekly Skin Observations for resident #11, dated 8/3/21, 8/13/21 and 9/15/21. She did not explain why the resident's weekly skin checks were not done. She explained the South [NAME] UM should have ensured they were done. The Administrator verbalized that direct care nurses completed the Weekly Skin Observations, but no one verified they were completed. The DON then stated the WCN did a head to toe check on residents. The WCN stated she did not do head to toe skin check every week on residents. The WCN said she placed a piece of foam under the resident #11's ear when the pressure ulcer was first discovered and if the foam needed to be repositioned, then the direct care nurse would do it. The DON noted the foam would have to be moved when the resident was repositioned. When informed the foam was not between the resident's ear and pillow on 10/25/21 and 10/26/21, the DON responded, it should have been. The DON explained the U shaped pillow was started yesterday, 10/27/21. On 10/28/21 at 12:44 PM, a meeting was conducted with the Chief Nursing Officer (CNO), Regional Nurse and Administrator regarding concerns with the right ear pressure ulcer. The CNO explained skin assessments on resident #11 were done by the physician's APRN G. She pointed out that APRN G saw the resident on 9/13/21 and did a head to toe skin assessment. On 10/28/21 at 1:44 PM, during a telephone interview, APRN G said she reviewed her progress note dated 9/13/21 and recalled she probably looked at resident #11's ears on this visit but she didn't note it. APRN G stated she tried to do a head to toe skin assessment when she examined the resident's sacral wound, but did not do a head to toe skin assessment on every visit. She stated she did not think the resident could have voiced his preference to be on his right side. She discussed ways to offload the pressure to his ears including turning him from side to side. She said she was informed about the U shaped neck pillow and agreed this would offload the pressure. She stated typical offloading was turning the resident from side to side. She explained the oxygen nasal cannula could had attributed to resident #11's right ear pressure ulcer. She explained padded tubing could had been used but there was no evidence the facility had tried padded oxygen tubing. APRN G reported she did not always do a head to toe skin assessment on every resident because she would need staff to assist with turning and repositioning and that staff were not always available. She acknowledged her note on 9/13/21 did not indicate a head to toe skin assessment was done. She stated, it's considered that if it is not documented, you didn't do it. On 10/28/21 at 2:46 PM, CNA E was in the resident's room and the resident was in bed asleep with the U shaped pillow around his neck and a foam piece between his right ear and neck pillow. CNA E said she often cared for resident #11. She identified 2 staff were required to turn and reposition the resident. She explained resident #11 preferred to be on his back. She said she had not seen the foam, that was under his right ear until today and the neck pillow was new since yesterday. On 10/28/21 at 3:27 PM, a meeting was held with the Therapy Director, Physical Therapist (PT) and the Certified Occupational Therapist Assistant (COTA). The therapy discharge notes were reviewed that indicated the resident had been on therapy from 8/22/21 to 9/10/21. A goal for Occupational Therapy noted, patient will achieve midline position in bed . The discharge summary noted on 9/10/21, Poor-unable ability to achieve midline. The therapist stated the resident leaned to the right and they tried to orient him to midline. The therapist said the resident leaned to the right maybe out of habit or related to multiple strokes. They stated they tried different approaches but the resident would always shifted his head to the right side. They acknowledged resident #11 did not have any purposeful movement and could not follow instructions. The Therapy Director explained the U shaped pillow was placed on him on 10/27/21 to aid with healing the right ear pressure ulcer. The therapists did not provide an answer when asked if they were consulted about off loading the ear prior to 10/27/21.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #35 was admitted to the facility on [DATE] with diagnoses of end stage heart failure, cirrhosis of the liver, dementia, abnormal finding of the lung field. The physician order sheet revealed an order dated 6/10/21 that read, oxygen at 2 liters/min via nasal cannula as needed (prn) for shortness of breath. The Quarterly Minimum Data Set, dated [DATE] indicated the resident was receiving oxygen and hospice care. A Care Plan dated 6/04/20 and revised on 9/09/20 and 3/11/21 read, . requires intermittent or PRN oxygen support. Goal: will maintain use of intermittent oxygen as directed . On 10/25/21 at 12:21 PM, resident #35 was observed lying in bed. He had oxygen via nasal cannula attached to an oxygen concentrator with oxygen flow rate at 3 liters/min. On 10/25/21 at 2:22 PM, the oxygen flow rate remained at 3 liters/min. On 10/25/21 at 4:05 PM, resident #35 was in bed and the oxygen flow rate was at 3 liters/min. On 10/25/21 at 4:12 PM, Licensed Practical Nurse, (LPN) H said she was assigned to resident #35. She stated the resident should have oxygen set at 2 liters/min via nasal canula. LPN H proceeded to resident #35's room, and acknowledged the oxygen concentrator was set at 3 liters/min. The LPN requested to have the Unit Manager (UM) come to the room. She informed the UM the resident's order for oxygen was for 2 liters/min and the UM verified the oxygen concentrator was set at 3 liters/min. The UM stated the expectation was that nurses check the oxygen concentrator at the start of the shift and periodically throughout the shift to ensure it was on the correct flow rate. Policy and Procedure: Physician Services dated 3/02/19 and revised 3/02/19 stated, 8. All physician orders will be followed as prescribed . Based on observation, interview and record review, the facility failed to follow physician orders for respiratory therapy for 2 of 3 residents reviewed for respiratory care of a total sample of 35 residents, (#54, #35). Findings: 1. Resident #54 was readmitted to the facility on [DATE] with diagnoses of cerebral infarction, acute respiratory failure, and tracheostomy. The resident's Minimum Data Set (MDS) assessment with reference date 9/26/21 revealed the resident had a tracheostomy, received oxygen therapy, and suctioning. Resident #54 had care plan dated 12/05/18 for tracheostomy related to respiratory failure. She required continuous use of supplemental oxygen and care plan included interventions to, Observe respiratory rate, depth and quality oxygen as per orders On 10/25/21 at 12:50 PM, resident #54 was noted with oxygen therapy via her tracheostomy collar at 3 liters per minute (LPM). Review of the medical record revealed resident #54's physician order dated 10/25/21 read, Oxygen continuous at 5 liters/min via tracheostomy mask . On 10/25/21 at 2:30 PM, the resident's assigned nurse, Licensed Practical Nurse (LPN) B said her assignment sheet did not indicate resident #54 had oxygen and she did not check the oxygen rate today. On 10/25/21 at 2:25 PM, LPN A checked the resident's physician order for oxygen and stated it should be at 5 LPM. LPN A then went to resident #54's room, looked at the flow rate at eye level and said, I now see it is at 3 LPM. LPN A attempted to adjust the gauge on the concentrator and said it was broken and needed to be replaced. On 10/26/21 at 4:15 PM, resident #54 was noted with oxygen therapy via her tracheostomy collar at 2.5 LPM. On 10/26/21 at 4:20 PM, LPN L checked the physician order for resident #54's oxygen and said the order was changed from 5 LPM to 3.5 LPM. LPN L proceeded to resident #54's room and acknowledged the concentrator was set at 2.5 LPM. On 10/27/21 at 4:52 PM, the Director of Nursing (DON) stated the nurses should know the orders and check the oxygen liter rate at least once per shift, and whenever in the resident's room.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that pain management was provided consistent with professional standards of practice for 1 of 1 sampled resident, (#11) in a total sample of 35 residents. Findings: The National Pressure Injury Advisory Panel (NPIAP) redefined the definition of a pressure injury (formerly pressure ulcer) in 2016. The updated staging system includes the following definitions: Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence .Stage 4 Pressure Injury: Full-thickness skin and tissue loss . If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury (www.npiap.com). Resident #11 was admitted to the facility on [DATE] and re-admitted on [DATE] from an acute care hospital with diagnoses of strokes, dysarthria, malignant neoplasm of sigmoid colon, unstageable pressure ulcer of sacral region, diabetes type 2, gastrostomy, protein calorie malnutrition and pain. Review of the hospital medical records revealed a history and physical dated 8/1/21 that read, patient is nonverbal and non-communicative admitted to the hospital with altered mental status nearly vegetative state. Patient is not a candidate for any aggressive cardiac intervention outcomes of this patient is exceedingly poor. The most recent Minimum Data Set (MDS) assessment dated [DATE] showed resident #1's cognition was rarely/never understood. The resident was totally dependent on 1-2 persons for all activities of daily living (ADL) and was bedbound. Within the last 5 days prior to the MDS assessment, the resident had not received any scheduled or prn (as needed) pain medication and received no non-medication interventions for pain. The staff assessment for pain did not show any non-verbal sounds, facial expressions, or protective body movements for pain. A care plan dated 8/6/21 for potential alteration in comfort related to muscle weakness, sacral and ear wounds noted pain is often displayed by changes in body mechanics, i.e., tightening/stiffening, etc.rather than with facial movement/grimaces which are more a form of acknowledgement/communication than pain/discomfort include interventions to, Evaluate for nonverbal indicator of pain including but not limited to body tensing/stiffening, moaning, rapid/increased breathing and or/restlessness and evaluate the effectiveness of pain control and document, notify MD [Medical Doctor] if pain control is ineffective, and medicate for pain as ordered. The care plan revised 10/12/21 for unstageable pressure ulcer sacrum and stage 3 pressure ulcer right ear did not address potential for pain caused by dressing changes/wound care. There were no interventions to address potential for pain during wound care such as observe for non-verbal signs of increased discomfort with wound care. There were no goals mentioned to ensure resident #11's comfort would be maintained during wound care performed by nurses. According to the most recent MDS assessment and weekly wound evaluation forms, resident #11 was admitted with unstageable pressure ulcer/injury to his sacrum and developed a stage 3 pressure ulcer/injury of the right ear in the facility as of 9/15/21. The ear wound worsened and became a stage IV as of 9/23/21. The care plan for pressure ulcers did not address the potential for pain during wound care/procedures. Review of the facility Weekly Wound Evaluation form dated 10/25/21 revealed presence of the following wounds: Right ear facility acquired wound measuring 2 centimeters (cm) by 0.3 cm by 0.3 cm deep with 30% granulation tissue and 70%. The pressure unstageable pressure ulcer on the sacrum measured 1.5 cm by 1.3 cm by 0.1 cm deep with 10% granulation and 90% eschar. On 10/26/21 at 4 PM, resident #11 was observed resting in bed and appeared asleep with no signs of distress or discomfort noted. On 10/27/21 at 11:02 AM, the Wound Care Advance Practice Registered Nurse (APRN) M and Wound Care Physician Assistant (PA) N were on the North Wing of the facility rounding on residents. The APRN explained that resident # 11's ear wound was considered a stage 4 as there was no fat, muscle or bone in the ear. Since cartilage is the supporting structure, her guidance was to classify the wound as a Stage IV. The APRN indicated she had a busy schedule today and would see resident #11 later. She indicated she had another facility to visit after this one. On 10/27/21 at 12:45 PM, an observation of resident #11's wound care was conducted with the Wound Care Nurse (WCN), APRN-M, Physician Assistant and the Director of Nursing (DON). The APRN and WCN proceeded to turn the resident onto his left side and the DON began to remove the soiled brief. During turning the resident was observed with facial grimacing and slightly tightened his upper body. After the soiled brief was removed an observation of sacral wound revealed moist wound with yellow slough and surrounding pinkish/red tissue. The APRN proceeded to measure the sacral wound and called out the following measurements to the PA, 1.6 centimeters (cm) x 1.3 cm x 0.1 cm deep. During the procedure the WCN was holding the resident onto his left side while the APRN proceeded to clean the wound with normal saline (NS). The residents' facial expressions of wincing/grimacing became more exaggerated, as did tightening of the upper torso and he started moaning. The staff were asked to stop and were questioned whether the resident was medicated for pain prior to wound care. The staff continued with the dressing change and remarked that this was his usual during wound care. Staff indicated they thought he had Tylenol but could not say what time it was given or if they waited long enough for it take effect. The staff then positioned the resident onto his back and proceeded to do the wound care to his right ear. The ear wound appeared moist pink/red in color. The APRN called out the wound measurements to the PA of 1.7 cm x 0.6 cm x 0.2 cm deep. When the staff started to clean the ear wound with NS the resident again had increased grimacing, wincing, moaning and started to shake his head back and forth. The staff were again asked again to stop the procedure but proceeded with the wound care. The DON was asked why wound care was not stopped and she remarked that the physician would be called today for an order for stronger pain medication. The WCN said she did his wound care twice daily at 9 AM and between 3-4 PM. She commented that this was the resident's usual disposition during wound care. She did not provide an answer when asked why she did not get something stronger for the resident's pain sooner. The APRN and DON were interviewed post wound care outside the resident's room. The APRN said that normally during wound care, they did not turn the resident onto his left side as this caused him discomfort. She added they turned him onto his uncomfortable side so the surveyor could observe his wound. They were informed that was no requested nor acceptable or discussed prior to this observation. The APRN stated that they visited every week and would have expected the facility to pre-medicate him for pain. The APRN was asked why she did not stop the wound care and wait for staff to order stronger pain medication, she stated, I don't know, we were nervous due to being observed. On 10/27/21 at 1:45 PM, the resident's assigned Register Nurse, (RN) D checked the Medication Administration Record (MAR) and said the resident received Tylenol 325 milligrams 2 tablets via gastrostomy tube at 12:31 PM which was 14 minutes prior to wound care. The RN explained he did not see the resident in any pain when lying in bed. It is only when they are doing care. On 10/21/21 at 1:50 PM, resident #11 was observed supine resting in bed with a U shaped pillow around his neck and showed no distress or pain. On 10/27/21 at 4:32 PM, an interview was conducted with the WCN, DON, Assistant Director of Nursing (ADON) and Regional Director of Regulatory Compliance (RDRC). The ADON said she had helped with the resident's care and anytime staff touched him, he would flare his nose, raise his eyebrows, had facial grimacing and moaned at times with re-positioning. The DON said they did not feel resident #11 was in enough distress to stop the procedure and they took a break between doing the 2 wounds. The DON acknowledged resident #11's reactions escalated when they touched the wounds. The WCN said she had not checked the time Tylenol was given and did not realize that it had only been given 15 minutes prior to wound care which was not enough time to be effective for pain. On 10/27/21 at 5:29 PM, Certified Nursing Assistant (CNA) E said resident #11 was on her assignment twice per week. She said the resident tightened his shoulders and moaned a little when turned, bathed or provided care. She added that he was fine when just lying on his back. On 10/27/21 at 5:35 PM, the Director of Therapy acknowledged resident #11 was on therapy last month for positioning and comfort. She said, the resident made faces and tightened up during positioning. We would know to stop the therapy when he would resist and try to get on to his back. The Therapy Director reviewed the therapy note dated 8/23/21 regarding pain and said, the patient is unable to communicate pain or lack of. It is to be determined based on patient behavior. The Therapy Director explained, when resident #11 started to move his head back and forth that would indicate he was trying to get away from pain. On 10/28/21 at 10:26 AM an interview was conducted with the WCN, DON, Executive Director (ED) and RDRC. The ED assisted with interpreting Spanish to English for the WCN. The WCN said, it was explained to her by the APRN that facial expressions were normal for resident #11 because he had history of 4 strokes. She said she thought all staff were aware that wound rounds were being done and she assumed the resident had been medicated but did not know when the Tylenol was given. The WCN said she normally went to the units and informed nurses to give pain medications 30-45 minutes prior to wound care. The DON said, we did not feel he was experiencing any additional pain except when she was cleaning the wounds and it was not for a prolonged period that he had pain. Review of the medical record with the facility staff acknowledged resident #11's pain was not addressed in the comprehensive care plan regarding potential for pain during wound care. The WCN stated, because he had never showed true discomfort it was not included in the plan of care. The staff acknowledged the Weekly Wound Evaluation assessment done by the WCN on 8/4, 9/13, 8/19, 8/27, 9/3, 9/10, 9/17, 9/23, 9/30, 10/8, and 10/15/21 were all inaccurate as the nurse documented the resident was cognitively intact and thus the assessment for no verbal signs of pain was not triggered/nor completed. The DON was asked if she checked the WCN's documentation and stated, I am just one person. The facility staff acknowledge the resident was not able to verbalize pain and that his facial expressions were a sign of discomfort as the resident did not know if staff were doing wound care or changing his brief. On 10/28/21 at 1:59 PM, during a telephone interview, the primary care physician's APRN G said the resident was vegetative and his pain was assessed by non-verbal indicators such as facial grimacing, body tensing, resisting care or becoming rigid. She added if pain medication was given after wound care, it's too late. The APRN added, it is a priority for him not to be in pain. Review of the facility policy and procedure for pain management revised 3/2/19 read, each resident receives necessary care and services in accordance with professional standards of practice The facility must ensure that pain management is provided to residents Behavioral signs and symptoms that may suggest the presence of pain include .Resisting care .Facial expressions: grimacing .Sighing, groaning Assessment and evaluation by appropriate member of the interdisciplinary team may include .Determining factors that may make the pain better or worse the interdisciplinary team is responsible for developing a pain management regiment .If when re-evaluating, findings indicate pain is not adequately controlled, revise the pain management regimen and plan of care as indicated

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observation, interview and record review, the facility failed to ensure dishes were washed at the appropriate temperature, as per the data plate and manufacturer's instructions. Finding: On 10/25/21 at 9:25 AM, Dietary Aide K placed a dish rack containing dishes into the dish machine. The dial on the dish machine showed temperature at 150 degrees Fahrenheit (F). The Data Plate on the machine, noted the wash temperature should be 160 degrees F. Dietary Aide K placed another rack of dishes into the dish machine and the wash temperature rose to 152 degrees F. Dietary Aide K said she started washing dishes at 9:20 AM and had already stored dishes that she had washed. The Regional Dietary Director acknowledged the wash temperature should be 160 degrees F. and the final rinse temperature should be 180 degrees F. The Certified Dietary Manager (CDM) produced the temperature log book for the dish machine dated 10/25/21 which noted the wash temperature should be at 160 degrees F. and the final rinse should be 180 degrees F. The Food and Drug Administration 2017 Food Code notes in section 4-501.15A, that a warewashing machine and its auxiliary components shall be operated in accordance with the machines data plate and other manufacturer's instructions.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Garbage Disposal (Tag F0814)

Could have caused harm · This affected multiple residents

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Based on observation and interview, the facility failed to ensure garbage and refuse was disposed in a sanitary manner. Finding: On Monday, 10/25/21 at 9:25 AM, an uncovered dumpster was observed located at the back of the facility. The dumpster did not have a cover lid. The Certified Dietary Manager (CDM) said the dumpster was used by maintenance. The maintenance dumpster contained picture frames, old furniture, clear trash bags containing paper, food cartons and juice cups. The CDM stated that food items should not be in this dumpster. The Maintenance Assistant arrived at the site and acknowledged that food refuse should be in the regular dumpster and not in the maintenance dumpster. The CDM stated food and food cartons should be in the closed dumpster to prevent rodents and pests. The Food and Drug Administration's 2017 Food Code refers to the use of outside receptacles for waste in chapter 5-501.15(A). Receptacles and waste handling units for refuse, recyclables and returnables used with materials containing food residue and use outside the food establishment shall be designed and constructed to have tight-fitting lids, doors, or covers.

Feb 2020 1 deficiency

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Garbage Disposal (Tag F0814)

Could have caused harm · This affected 1 resident

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Based on observation and interview, the facility failed to ensure waste was contained and the garbage area was clean and free of debris. Finding: On Sunday 2/9/19 at 10:21 AM, the dumpster area at the back of the facility was noted to be unclean. There were disposed individual condiment packages that included salt, pepper, tarter sauce, numerous amount of cigarette ends and other debris near the 3 dumpsters. One of the dumpster's lid was open. At 10:45 AM, the certified dietary manager (CDM) arrived at the facility and stated that maintenance staff was responsible for keeping the dumpster area clean. The CDM added that no one should be smoking behind the dumpsters as there was a designated area for employees to smoke. The CDM said the dumpster doors must be closed and the area maintained in a sanitary condition to prevent the harborage and feeding of pests.

Nov 2018 15 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

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Based on observation and interview, the facility failed to accommodate a preference to use side rails on the bed, for 1 of 55 sampled residents (#72). Findings: Resident #72 had diagnoses including stroke, heart failure, generalized muscle weakness and difficulty walking. The Minimum Data Set (MDS) quarterly assessment with assessment reference date of 10/16/18 revealed resident #72 had clear speech, was able to express ideas and wants, and had clear comprehension. She required extensive assistance from staff for bed mobility, transfers, dressing and personal hygiene. Resident #72 was unsteady during transfers and could stabilize only with assistance from staff. She had limitation in range of motion of her extremities on one side and used a wheelchair for mobility. The assessment showed resident #72 did not have side rails on her bed. On 11/13/18 at 11:17 AM, resident #72 stated she wanted side rails for her bed. She said, I've asked the head nurses and maintenance. She explained she slept on her back because she was afraid to roll to her side and fall off the bed. On 11/15/18 at 12:03 PM, resident #72 recalled she first asked the maintenance assistant about getting side rails attached to her bed. She explained she asked several staff members in the last 6 months, and discussed it again with the maintenance assistant as recently as within the past week. Resident #72 said,I really need them. She explained she once fell out of bed when she reached for a fork on the floor. She said, If I had side rails, I would have been able to hold on. Resident #72 stated it would also help to have side rails when staff rolled her from side to side in bed to provide care. On 11/15/18 at 3:17 PM, the maintenance assistant acknowledged resident #72 asked him about getting side rails for her bed more than 3 months ago. He explained he was not permitted to install side rails without authorization from nursing staff and his supervisor. The maintenance assistant stated he informed a member of the nursing staff of resident #72's request but received no follow-up. On 11/15/18 at 3:33 PM, certified nursing assistant (CNA) K stated she was aware resident #72 wanted side rails installed on her bed. She recalled resident #72 told her, One of these days I'm going to fall out of this bed. CNA K explained resident #72 had gained weight and felt she was too large to safely roll over in the bed. CNA K confirmed resident #72 asked her about getting side rails for her bed. She said, I told a nurse but I don't remember who. I think I also mentioned it to a co-worker. CNA K stated resident #72 required assistance for transfers and moving in bed. She acknowledged side rails would be helpful as resident #72 was weak on one side of her body. On 11/15/18 at 5:55 PM, registered nurse L validated resident #72 was alert, oriented and able to make her needs and wants known. She acknowledged resident #72 was a reliable historian, and surmised that staff probably did not follow up on resident #72's request for side rails. On 11/16/18 at 3:04 PM, the Assistant Director of Nursing stated her expectation was facility staff would communicate residents' requests appropriately, and accommodate their preferences if possible.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide housekeeping and maintenance services to ensure a clean, safe and homelike environment in 3 of 24 rooms on the North Wing (124, 128 & 140). Findings: 1. On 11/13/18 at 1:03 PM, an inspection of room [ROOM NUMBER] revealed the ceiling tiles above bed A were not fitted properly in the supporting frame. Gaps between the ceiling tiles, the frame and surrounding wall exposed small areas of pink insulation material. Small particles of the insulation fell from the ceiling onto the resident in bed A and a visitor seated on a chair to the left of the bed. Across the room, a capped hose approximately 18 inches long, attached to the cold water supply line of the pedestal sink, protruded into the room at a 45 degree angle. Beside bed B, there was a wall-mounted air conditioning (AC) unit that was displaced from the wall about 1.5 inches. There were gaps between the wall and the air conditioner (AC) unit and remnants of old caulking around the edges of the AC unit's front panel. 2. On 11/15/18 at 4:37 PM, inspection of room [ROOM NUMBER] revealed a gap between ceiling tiles and the wall behind bed A. The ceiling tiles directly above bed B had significant sagging noted in the center of each tile. One ceiling tile above the window had a brown circular stain that covered approximately half the tile. The AC unit was displaced about 3/4 inch from the wall, and evidence of old caulking was visible around the unit. On 11/16/18 from 9:55 AM to 10:19 AM, a tour of rooms [ROOM NUMBERS] was done with the Director of Plant Operations (DPO). In room [ROOM NUMBER], the DPO acknowledged the AC unit did not fit the sleeve properly and noted someone used caulking to try and fill the gap around the unit. He described it as ugly. The DPO then checked the hose protruding from the right side of the pedestal sink and said, It is a water line, but to what I don't know. He validated the ceiling tiles above bed A did not fit properly and needed to be replaced. In room [ROOM NUMBER], the DPO confirmed the ceiling tiles were sagging, stained, improperly fitted and needed to be replaced. He stated the ceiling tile with the brown stain appeared to be old water damage. The DPO acknowledged the AC unit did not fit the sleeve in the wall. He suggested the spaces around the AC units in both rooms should have been covered with trim rather than caulking. The DPO acknowledged rooms [ROOM NUMBERS] did not have a pleasant, homelike appearance. The DPO explained he inspected the facility's common areas regularly, but did not do preventative maintenance rounds in residents' rooms. The DPO explained he depended on department heads who conducted room rounds every morning or housekeeping and direct care staff who were in residents' rooms regularly throughout the day to report any maintenance issues. He said, My assistant and I go into rooms when something is reported. We do focused visits but do not look at everything. On 11/16/18 at 2:59 PM, the assistant director of nursing (ADON) confirmed department managers were required to check assigned rooms every morning. Review of the Room Round Assignments form (revised 1/25/18) with the ADON revealed the Staffing Coordinator was responsible for daily inspection of 124 and the Business Office Manager was responsible for daily inspection of room [ROOM NUMBER]. She provided a copy of the Patient Satisfaction & Environmental Customer Service Daily Rounding Tool form that should be used to document environmental concerns. She explained staff were expected to give completed forms to the administrator, but said, We don't always fill out the form. We need to do education regarding things to look for in the environment. Review of work orders logged in the building management computer program for October and November 2018 revealed no reports of the concerns identified in rooms [ROOM NUMBERS]. The facility's policy and procedure for Preventative Maintenance Program, revised 1/01/18, revealed the intent to provide a safe, functional, sanitary and comfortable environment for residents, staff, and the public. The document indicated the Maintenance Director was expected to develop and implement a schedule of maintenance services and assess all aspects of the facility to identify preventative maintenance needs. The policy revealed required preventative maintenance could be determined from maintenance requests and grand rounds. 3. Observations conducted in room [ROOM NUMBER] on 11/15/18 at 9:08 AM, 12:34 PM and 3:39 PM, and on 11/16/18 at 7:46 AM and 7:50 AM revealed the wall behind the head of the bed for 128 B to have multiple dark brown stains. The wall behind the head of the bed for 128 A to have light brown drip stains from the ceiling down the wall. On 11/16/18 at 7:50 AM the North Wing Unit Manager (NWUM) stated that she conducts daily room rounds in all of the resident rooms observing for room cleanliness. The NWUM confirmed the above findings and stated that the wall needed to be cleaned. On 11/16/18 at 7:50 AM the Assistant Director of Nursing/Infection Control Nurse confirmed that the wall in room [ROOM NUMBER] was soiled. On 11/16/18 at 7:57 AM, the Environmental Services Director stated that the North wing has one (1) Housekeeper assigned to clean 24 rooms, 1 resident room for deep cleaning per day, the nurses' station and the dining areas all in a 7 hour shift. She said, This is way more rooms than the housekeeper can handle. Review of the Contracted Housekeeping Company Name, Daily Patient Room Cleaning, dated 6/2016, read, Timing and Method 3) Spot clean. With a cloth and disinfectant spot clean all vertical surfaces Review of the Facility Name, Room Round Assignments dated 1/25/18, read, Staffing Coordinator .128

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that the bed hold notice was given to the resident or representative at the time of transfer or as soon as possible after admission to the hospital for 1 resident reviewed for hospitalization (#33). Findings: Resident #33 was admitted to the facility on [DATE] from the hospital with diagnoses including chronic respiratory failure, hemiplegia and hemiparesis, encephalopathy, and multiple pressure ulcers. A review of the medical record revealed that on 10/30/18 at approximately 9 PM, the resident's wife informed staff the resident was having shortness of breath and mucous in his trachea. The nurse attempted to suction the resident but was unable to insert the catheter for suctioning. The oxygen (O2) saturation was 85-86% on 2 liters of oxygen. The O2 was increased to 3 liters with no O2 saturation improvement. The physician and emergency services were contacted. The on-call nurse practitioner ordered the resident to be sent to the hospital. There was no documentation in the clinical record that a bed hold notice was given to the resident or his wife at the time of discharge. There was no copy of the notice or a progress note stating that the information was provided. On 11/16/18 at 2:45 PM, an interview with the north wing unit manager (UM) revealed that the nurse at the time of the transfer to the hospital should have completed the forms. A copy was not kept. The North wing UM was not aware that the form had to be given to the resident or responsible party. On 11/16/18 at 2:48 PM, an interview with the medical records staff revealed that it was nursing responsibility to complete and send the transfer and bed hold form. On 11/16/18 at 3:03 PM, an interview with the admissions coordinator revealed that the bed hold policy was in the admission packet. She had no responsibility after admission for bed hold notices. Review of the facility acute care transfer document checklist noted the following information: inclusion of the transfer form, bed hold policy notice and information to be sent to the hospital. Review of the facility Bed hold and readmission Policy (ADM-FL), effective 8/15/16, Bed hold defined the bed will be held if the facility has an occupancy of at least 95 %. The bed will not be held if the Medicaid occupancy was below the 95%. If the resident while in the hospital chooses not to return, the hospital of the resident is to notify the facility prior to the end of the 8-day allowable period. On 11/16/18 at 3:35 PM, the administrator confirmed that there was no documentation to confirm that bed hold notice and transfer notice were given to the resident or responsible party at the time of transfer or after they were admitted to the hospital.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0676 (Tag F0676)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that 1 of 1 resident reviewed for hearing loss received the services to assist the resident in his ability to improve his hearing, (#78). Findings: Resident #78 was admitted to the nursing home after a hospitalization for left fractured hip with artificial hip replacement. On 11/15/18 at 10:09 AM, the resident repeatedly made requests to speak louder since he was hard of hearing. He stated that his left ear was much worse than his right ear. He said that he saw an audiologist a few months ago and was told he would have hearing aids in about two weeks. He had not received any hearing aids or assistive devices since them. Review of clinical record revealed an order for Audiologist consult. A progress note reflected a scheduled appointment on 8/29/18. There no further documentation in the resident's medical record related to the appointment. There was no documentation of the appointment. There were no results from the visit. On 11/15/18 at 4:42 PM, the social services assistant revealed that the facility tried to get him an appointment. They could not find a physician that accepted his Medicaid insurance. On 11/15/18 at 4:55 PM, licensed practical nurse A confirmed that he had been hard of hearing and had no assistive devices. She confirmed that no appointment for a hearing consult had been made due to insurance payment source. Review of the significant change minimum data set assessment (MDS), dated [DATE], revealed that resident #78's hearing was highly impaired and that he no hearing aid or other hearing appliance. A quarterly MDS assessment dated [DATE] also noted severe hearing impairment and no assistive hearing devices. Review of the plan of care initiated 6/01/18 and revised on 8/21/18 identified that resident #78 was identified that he was hearing impaired with no hearing in his left ear and has difficult time hearing of his right ear. Interventions included to use a megaphone to help communicate with resident. Put megaphone up to resident's right ear. The goal was to be able to make needs known through next review. Other interventions included: Approach resident in a manner that will not surprise or startle him. An auditory consult dated 6/01/18, minimize background noise. Refer Resident # 78 for a device intervention as appropriate. There was a documented order for Audiologist consult on 8/29/18. On 11/15/18 at 5:05 PM, the director of rehabilitation stated that he had not received any referrals to assess for assistive hearing devices, which he would refer to the speech therapist. The speech therapist would help assess his condition and make recommendations for a temporary device. On 11/16/18 at 11:30 AM, the speech pathologist said that when a resident has been identified with a hearing loss, that was a severe impairment, she would try an assistive hearing device that amplified sound using head phones. She would ask family if the resident had any hearing device prior to admission. No one had asked her to assess Resident #78's hearing loss. The resident was never given any assistive device or referred to therapy services to help improve his ability to hear information shared by staff or assist him communicating with other residents.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide personal grooming related to removal of facial hair for 1 of 5 residents reviewed for activities of daily living, (ADLs), (#61). Findings: Resident #61 was admitted on [DATE] with diagnoses of vertigo (sensation of feeling off balance), repeated falls, difficulty in walking, muscle weakness. The Minimum Data Set (MDS) 14-day assessment with assessment reference date of 10/15/18 revealed resident # 61 was alert and oriented however she needed extensive assistance of one person for dressing and personal hygiene. On 11/13/18 at 11:05 AM, resident #61 was seen seated in her wheelchair in the common dining area of the North Wing. She was noted to have several white facial hairs on her chin area, approximately half inch long. The following day, 11/14/18 at 9:07 AM, resident #61 was lying in bed. She still had long facial hair. At 1:36 PM, resident #61 sat in the common dining area in the North wing and her facial hair was still noticeable. On 11/15/18 at 9 AM, resident #61's facial hair remained unchanged. At 10:32 AM, resident #61 stated she would like her facial hair to be shaved regularly. She explained when she was at home, she was doing it by herself. On 11/15/18 at 11:07 AM, certified nursing assistant (CNA) Q stated that resident #61 was always cooperative with ADL care. At 2:50 PM, in an observation with the North wing unit manager (UM), she validated that resident # 61 had long facial hair. When the UM asked the resident if she wanted it removed, the resident replied yes. The UM acknowledged it was any CNA's responsibility to provide assistance with grooming. Review of resident #61's medical records on 10/02/18 revealed a care plan for grooming assisted by staff. The care plan goal was resident will be well groomed on a daily basis. The intervention included to allow resident to direct grooming. Review of progress notes from October to November 2018 revealed no documentation of refusal of ADL care for this resident. The policy and procedure for Activities of Daily Living, Supporting, revised March 2018, indicated that residents who are unable to carry out ADL will receive the services necessary to maintain good grooming and personal hygiene. Review of the CNA job description revealed that the CNA is expected to assist residents with bathing and grooming.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure proper hand hygiene and technique to prevent cross-contamination during pressure ulcer treatment observation for 1 of 4 residents reviewed for pressure ulcers, (#62). Findings: Resident #62 was admitted on [DATE] with diagnoses of pressure ulcer of sacral region and osteomyelitis (infection of the bone). The minimum data set (MDS) significant change in status assessment with assessment reference data (ARD) of 10/05/18 revealed resident #62 had an unhealed stage 3 pressure ulcer located on sacrum. Stage 3 pressure ulcer are sores that have gone through the second layer of skin into the fat tissue that look like a crater and may smell bad. (www.webmd.com) Review of wound care physician's Wound Assessment, dated 11/15/18, revealed resident #62 had a stage 3 pressure ulcer on sacrum with measurements 7.0 centimeters (cm.) by 1.0 cm. by 0.2 cm., and had heavy drainage. The physician's verbal order on 11/15/18 was to cleanse sacral wound with normal saline, pat dry, apply periguard barrier cream to periwound, calcium alginate to wound bed then cover with dry sterile dressing every day shift and as needed. On 11/15/18 at 12:40 PM, licensed practical nurse (LPN) E provided wound care to resident #62. She entered the room with treatment supplies in her left hand, placed them on top of bedside table without sanitizing or placing a barrier on the bedside table. She positioned the resident on his left side, opened his brief to expose the sacral area and removed the 4 by 4 gauze saturated with bloody drainage. After removing the soiled gauze, LPN E did not wash her hands and don new gloves. She used the same gloves to soak a clean gauze with Normal Saline then cleansed the wound bed and peri-wound area. She used another 4 by 4 gauze to pat dry the area, then placed all soiled dressings on the drape below the wound. Without sanitizing or washing her hands, LPN E changed her gloves then applied barrier cream around the wound and placed calcium alginate on top of wound bed. She realized that she had missing supplies needed to continue with the procedure, so she removed her gloves and went to her treatment cart outside the room. Meanwhile, resident #62 rolled over on top of all the soiled pads that were left on the bed. LPN E returned then applied clean gloves and rolled resident #62 off the soiled gauze. She continued with the procedure and applied a dry sterile dressing on top of the wound. On 11/15/18 at 12:52 PM, LPN E acknowledged that she failed to sanitize the table and place barrier before setting up the treatment supplies. She also explained she did not wash hands and change gloves after removing the soiled gauze from the wound and prior to dressing change. On 11/15/18 at 2:39 PM, the North wing unit manager (UM) verbalized she reviewed policy and procedure (P&P) on wound care with LPN E. She stated her expectation was LPN E would practice hand hygiene, dirty and clean procedures in wound care and would avoid contaminating the wound with soiled materials. Review of the facility's policy and procedure on Wound Care, revised October 2010, directed nurses to review the resident's care plan prior to wound care. The policy revealed nurses should assemble the equipment and supplies needed as part of preparation. Washing and drying of hands thoroughly were required prior to succeeding steps of the procedure to prevent further infection. Changing and donning gloves during the treatment were emphasized as well.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide care and services for 1 of 3 residents reviewed for urinary catheters, (#390). Findings: Resident #390 was admitted to the facility on [DATE] with diagnoses including renal dialysis, neuromuscular dysfunction of the bladder, diabetes mellitus, septicemia and respiratory failure. A review of the care plan dated 11/13/18 for urinary catheter read to report to physician signs and symptoms of urinary tract infection such as dark, cloudy, blood tinged urine, foul smelling urine, no urine output .Position catheter bag and tubing below level of bladder .Observe for pain or discomfort. A review of the certified nursing assistant, (CNA) [NAME] read, report dark color urine to the nurse. The resident was observed in bed on 11/14/18 at 9:00 AM. The indwelling urinary drainage bag was noted on the floor draining brown urine. There was a strong foul urine odor noted around the drainage bag and in the room. The resident's roommate asked, Do you smell urine? An interview with the certified nursing assistant (CNA) D on 11/15/18 at 12:08 PM revealed that the resident required total care with all activities of daily living. She stated that there was a very foul odor to the resident's urine and the color of the urine was bloody red. She said she informed the registered nurse (RN) C and asked her to assess the urinary drainage. On 11/15/18 at 12:20 PM the resident was again observed with dark amber colored urine with foul odor A review of the Treatment Administration Record (TAR) read, record urinary catheter output per shift. The TAR showed that all shifts documented with initials that urinary output was recorded. There was however no documentation of dark, bloody, foul smelling urine. An interview with RN C on 11/15/18 at 2:31 PM revealed that she had not been informed by the CNA D about the dark brown, foul smelling urine. She then said, that she was mistaken and had been informed by CNA D about the foul smelling, dark urine. She said that she should have checked the urinary output and called the physician as it could be an infection. She did not provide an answer when asked how the foul smelling dark urinary output was not addressed sooner despite all shifts documenting urinary output on the TAR. On 11/16/18 at 4:53 PM, the north wing unit manager (UM) was asked about any results of urine tests. She stated that a urine test was done. She obtained the lab result from a pile of faxed results near the fax machine. The form showed that the urine test results were faxed to the facility at 9:45 AM. She did not answer when asked why the results were not reviewed until requested by the surveyor, 7 hours after they were faxed to the facility She read the results and stated that she would call the physician right away. At 4:58 PM, the physician ordered antibiotics for resident #390 for a urinary tract infection.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 2/05/18, resident #6 was admitted to the facility with diagnosis including vascular dementia, diabetes mellitus, high blood pressure atrial fibrillation, peripheral vascular disease, anxiety, unsteadiness on feet, muscle weakness, benign prostatic hyperplasia and depression. Current medications included Coumadin 3 mg. per day, Aspirin 81 mg. per day, Lasix 40 mg. per day, Metoprolol 12.5 mg. twice a day, and Hydrocodone 5-325 mg. every 8 hours. Review of pharmacy recommendations dated 08/15/18 read, [Resident #6] receives Coumadin and Aspirin low dose, and medication that may increase the risk for bleeding. Recommendation: Please re-evaluate continued use of this combination. Physician's Response read, I decline the recommendation above and do not wish to implement and changes due to the reasons below. This was signed by the physician without being dated. There was no documented rationale for the declination of the pharmacy recommendation noted. Review of physicians progress notes dated 8/21/18 through 11/07/18 revealed no rationale for declining the pharmacy recommendation dated 8/15/18. On 11/15/18 at 12:43 PM, licensed practical nurse (LPN) A stated, The DON (director of nursing) gets pharmacy recommendations first and gives them to unit managers or to the nurses who put them in the physicians' books to be addressed. Once the physicians sign them, we input any new orders in the computer and the original goes back to the DON. On 11/16/18 at 10:15 AM, the DON stated the she receives monthly completed pharmacy recommendations, reviews them, makes copies for the resident charts and keeps the original in her pharmacy book. When it was pointed out that resident #6 did not have a rationale documented for the physicians declination of the pharmacist's recommendation on 8/15/18, she confirmed the finding. Based on observation, interview and record review, the facility failed to ensure pharmacy recommendations were reviewed and addressed by the attending Physician, and failed to ensure rationale for decline of pharmacy recommendation for 2 of 5 residents reviewed for Unnecessary Medication Regime Review (#6 & #51). Findings: 1. Resident #51 was admitted to the facility on [DATE] with diagnoses including depressive disorder and psychosis. The admission Minimum Data Set (MDS), dated [DATE], assessed the resident #51 as cognitively intact and receiving 7 days of antipsychotic, antidepressant, and antibiotic medications. The care plan, dated 10/18/18, included use of Seroquel, a psychotropic medication, anticoagulant therapy dated 10/31/18, bilateral cellulitis dated 9/27/18, and peripheral line intravenous for hydration and medication. Physician orders for November 2018 included Seroquel 300 milligrams (mg.) by mouth (po) 2 tablets at bedtime (HS) for psychosis, Digoxin 125 micrograms (mcg.) po daily for heart failure, and Enoxaparin 100 mg. per milliliter, inject 1 unit subcutaneous two times daily for deep vein thrombosis (DVT). Review of the Pharmacy Consultation Reports, dated October 15, 2018 through October 16, 2018, revealed 4 recommendations for resident #51's primary care physician to review but were not addressed as of 11/16/18. 1. Resident #51 was admitted with an order for an antipsychotic medication, Seroquel. Regulatory guidance requires re-evaluation of the use of psychotropic medications and consideration of whether or not such medications can be reduced or discontinued upon admission or soon after admission. If therapy is to continue, please provide detailed documentation of specific diagnosis/indication requiring treatment, symptom criteria/targeted behaviors, facility interdisciplinary team should ensure ongoing monitoring of specific targeted behaviors and document a 0 weather danger to self or others, (b) 0 desired outcome(s), (c) 0 the efficacy of individualized, nonpharmalogical approaches, and (d) 0 potential adverse consequences. This includes, but not limited to, evaluation for potentially reversible causes of behavior or psychological symptoms and assessment alternative interventions. 2. Resident #51 has been receiving the anticoagulant, Enoxaparin. This also requires a stop date as part of the medication order. 3. Resident is receiving two antibiotic agents that need stop dates. Minocycline 100 mg two times daily and the intravenous antibiotic, Ceftazidine 2 gram. 4. Resident #51 receives Digoxin, but does not have a serum digoxin concentration documented in the medical record. Please obtain a serum digoxin concentration on the next convenient lab day and annually thereafter. Review of Resident #51 medical record revealed no laboratory documentation for a Digoxin level. Review of the Policy 9.1 Medication Regimen Review, dated 11/26/16, read, Procedure 1. The Consultant Pharmacist will conduct Medical Record Reviews (MMRs) if required under a Pharmacy Consultant Agreement and will make recommendations based on information available in the residents' health record 6. The pharmacist will address copies of residents' MRRs to the Director of Nursing and/or the attending physician and to the Medical Director. Facility staff should ensure that the attending physician, Medical Director, and Director of Nursing are provided with copies of the MRRs. 7. Facility should encourage Physician/Prescriber or other Responsible Parties receiving the MRR and the Director of Nursing to act upon the recommendations contained in the MRR. 7.1 For those issues that require Physician/Prescriber intervention, Facility should encourage Physician/Prescriber to either accept and act upon the recommendation contained within the MRR, or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected. 7.2 The attending physician should document in the residents' health record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. 7.2.1 If the attending physician has decided to make no change in the medication, the attending physician should document the rational in the residents; health record. 8. Facility should alert the Medical Director when MRRs are not addressed by the attending physician in a timely manner . 11. The attending physician should address the consultant pharmacist's recommendation no later than their next scheduled visit to the facility to assess the resident, either 30 or 60 days per applicable regulation The Physician Progress Notes, dated 10/29/18, indicated that the attending physician was in to assess resident #51, and did not address the pharmacy recommendations for the month of October 2018. On 11/15/18 at 5 PM, the Director of Nursing (DON), Assistant Director of Nursing (ADON) and North wing unit manager confirmed that the October 2018 Pharmacy recommendation forms had not been addressed by the residents attending physician, there was no psychiatric progress notes in resident #51 medical record, and there was no behavior monitoring for use of an antipsychotic medication. The DON stated that the Social Worker is responsible for setting up the psychiatric consultations. On 11/15/18 at 5:40 PM, the Assistant Social Worker was unable to provide any documentation that the psychiatric consultation order, dated 10/08/18, had been set up or conducted. On 11/16/18 at 9:08 AM, the Administrator stated that the psychiatric evaluation was not set up because there was some insurance issues. He said, I was not informed of the issues so I could get it approved so that [resident #51] could see the Psychiatrist. On 11/16/18 at 10:14 AM, the ADON confirmed that there was no behavior monitoring for resident #51, and there has not been any behavior monitoring for the resident's psychotropic medication use since his admission on [DATE].

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide behavior monitoring and psychiatry consultation services for 1 of 5 residents receiving antipsychotic medication (#51). Findings: Resident #51 was admitted to the facility on [DATE] with diagnoses including depressive disorder and psychosis. The admission Minimum Data Set (MDS), dated [DATE], assessed the resident #51 as cognitively intact and receiving 7 days of antipsychotic and antidepressant medications. The care plan, dated 10/18/18, included use of psychotropic medication, Seroquel, for behavior management. The goal included to be free from drug related complications including movement disorder, discomfort, hypotension, gait disturbances, constipation/impaction or cognitive/behavioral impairment. The interventions included to monitor/record occurrences of for targeted behavior symptoms (Specify: pacing, wandering, disrobing, inappropriate response to verbal communication, violence /aggression towards staff/others, etc.) and document per facility protocol. On 9/27/18, the physician ordered Seroquel 300 milligrams (mg.) by mouth (po) 2 tablets at bedtime for psychosis. Review of the Medication Administration Record (MAR) for the month of November 2018 reflected that the resident received Seroquel 300 mg. 2 tablets po at bedtime from 11/01/18-11/15/18. There was no documentation of specific individualized behaviors for resident #51. On 11/16/18 at 10:48 AM, registered nurse (RN) C stated that resident #51 receives Seroquel 300 mg. 2 tabs a bedtime for psychosis. RN C said, I look for behaviors when I give [resident #51] his medications because he has psychosis. When asked what specific behaviors she is monitoring for resident #51 she stated, There are no behaviors for resident #51 in the system. Review of the facility Policy 3.8 Psychotropic Medication Use, dated 12/01/07, read, Applicability This Policy 3.8 sets forth procedures relating to psychotropic medication use. Definition A psychotropic drug is any medication that affects brain activities associated with mental processes and behavior. Procedure . 1.1.1 Facility staff should take a holistic approach to behavior management that involves a thorough assessment of underlying causes of behaviors and individualized person-centered non-drug and pharmaceutical interventions 4. Psychotropic medications to treat behaviors will be used appropriately to address specific underlying medical or psychiatric causes of behavior symptoms 12. Facility staff should monitor behavioral triggers, episodes, and symptoms. Facility should document the number and or intensity of symptoms and the resident's response to staff interventions Review of the physician's orders revealed a hand written order dated 10/08/18 to consult psychiatry to evaluate for therapy, diagnosis depression. Review of the November 2018 physician orders revealed an order dated 10/23/18 for psychiatry consultation. Review of resident #51 Medical Record revealed no documentation of psychiatry consultation.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review, the facility failed to follow physicians' orders to prevent medication errors for 2 of 6 residents sampled for medication administration (#34 and #87). There were 4 errors in 26 opportunities, for a medication error rate of 15.38%. Findings: 1. Resident #87 was admitted to the facility with diagnoses including epilepsy, type 2 diabetes and chronic lower back pain. His medical record included physician's orders for Keppra 500 milligrams (mg.) twice daily for seizures, Metformin 500 mg twice daily for diabetes and Oxycodone-Acetaminophen 5-325 mg. every 12 hours for pain. On 11/13/18 at 4:46 PM, registered nurse (RN) S gave medications including 1 tablet Keppra 500 mg., Metformin 500 mg. and 1 tablet Oxycodone-Acetaminophen 5-325 mg. Review of the medication administration record (MAR) revealed the medications were scheduled to be given at 9 PM. RN S stated she intended to administer only medication scheduled for 5 PM, but instead gave the three (3) medications, scheduled for later that shift, in error. RN S acknowledged she did not check the scheduled administration time for all medications before she gave them to resident #87. On 11/13/18 at 4:59 PM, the assistant director of nursing (ADON) confirmed nurses could administer scheduled medications within a 1 hour window either before or after the scheduled time. She acknowledged RN S administered the medications outside this window, 4 hours prior to the scheduled time indicated on the MAR. She validated it was a medication error and required notification to the physician and initiation of an incident report. 2. Resident #34 was admitted to the facility with diagnoses including hypertension. He had a physician's order for Amlodipine 10 mg. once daily to treat this condition. On 11/14/18 at 10:06 AM, RN C prepared resident #34's scheduled morning medications. She removed 1 tablet Amlodipine 10 mg. from a blister pack labeled with another resident's name and placed it in the pill cup. RN C placed the blister pack on top of the medication cart, and repeated the process until all scheduled medications were in the pill cup. On 11/14/18 at 10:12 AM, the labels on the blister packs were reviewed with RN C and the ADON. They validated the Amlodipine 10 mg. pack was prescribed for another resident, not resident #34. RN C acknowledged she made an error and pulled the wrong blister pack. She acknowledged she did not check the name on the label prior to placing the pill in the cup. The ADON recited the 5 rights of medication administration for RN C and confirmed RN C did not follow facility policy and professional standards for medication administration. The facility's policy and procedure for General Dose Preparation and Medication Administration, revised 1/01/13, revealed nurses should Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident The procedure directed staff to administer medications within specified timeframes.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure prescribed medication and treatment supplies were appropriately secured and inaccessible to residents, unauthorized staff and visitors in 1 of 2 treatment carts and 2 of 2 storage cabinets 1 of 2 units (North wing). Findings: On 11/14/18 at 9:15 AM, an unlocked treatment cart with the second drawer slightly open was observed opposite room [ROOM NUMBER]. The treatment cart was adjacent to 2 large, black cabinets, each approximately 6 feet by 4 feet. The assistant director of nursing (ADON) validated the treatment cart and storage cabinets were unlocked. Observation of the contents of the cart and cabinets with the ADON revealed all drawers of the treatment cart were well-stocked with prescribed ointments, creams, lotions and dressing supplies. The shelves in the storage cabinets were filled with wound care supplies and central supply items including bottles of hand sanitizer and tubes of barrier cream. The ADON confirmed the storage cabinets and treatment cart should be locked at all times, and be accessible by nurses only. There were residents and visitors seated in the nearby common area, and staff and residents passed by the unlocked treatment cart and cabinets. On 11/14/18 at 9:18 AM, licensed practical nurses (LPN) P stated she had been using supplies from the treatment cart and storage cabinets since 8 AM that morning. LPN P acknowledged she left the cabinets and treatment cart unlocked while she was doing wound care in residents' rooms. LPN P explained the nurses on the medication carts had keys for the treatment cart and cabinets, but she did not, so she left them unlocked while she worked and returned to get supplies as needed. On 11/14/18 at 9:44 AM, the North wing Unit Manager (UM) stated her expectation was medication and treatment supplies would be secured in locked areas. She explained it was standard nursing practice and facility policy to lock carts when unattended. The North wing UM confirmed the storage cabinets and the treatment cart should be locked to protect residents and prevent unauthorized access by staff and visitors. However, she admitted LPN P did not have keys for the storage areas. She stated the nurse who did wound treatments the previous day left the facility without returning the keys for the cabinets, and they had remained unlocked overnight. Review of the policy and procedure (P&P) for General Dose Preparation and Medication Administration, revised 1/01/13, read, Facility should ensure that medication carts are always locked when out of sight or unattended. The P&P for Storage and Expiration of Medications, Biologicals, Syringes and Needles, revised 10/31/16, read, Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart . that is inaccessible by residents and visitors. The procedure directed facility personnel to regularly inspect for compliance with storage requirements.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected 1 resident

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Based on observation and interview, the facility failed to ensure meal service was conducted in a manner to prevent cross-contamination and exposure to infectious pathogens on 1 of 2 wings (South). Findings: On 11/13/18 at 12:11 PM, an observation of the lunch meal service was conducted on the South wing. Resident #6 sat in his wheel chair at table with 2 other residents in the main dining area. Certified nursing assistant (CNA) B delivered a meal tray to resident #6. CNA B picked up the dinner roll with her bare hand and began placing butter on the dinner roll with a knife. CNA B stated that she has work at the facility for two and a half months and no one had ever told her any other way to butter a resident's roll. On 11/13/18 at 12:13 PM Licensed Practical Nurse (LPN) A stated, We do not touch the residents' food with our hands. We need a barrier such as a napkin between our hands and the food. We use a barrier for infection control reason so we don't spread infections from our hands to the resident. Review of the facility Infection Prevention and Control Program, dated June 2016, read, Policy: It is a policy of this facility to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections. Policy Explanation and Compliance Guidelines 2. The Registered Nurses (RN's) and LPN's supervise direct care staff in daily activities to assure appropriate precautions and techniques are observed Review of the Assisting Residents with Eating - Infection Control, dated March 2016, read, Policy: It is the policy of this facility to provide Residents with assistance with meals as needed. Policy Explanation and Guidelines 4. DO NOT handle actual unwrapped food items with your bare hands food handling gloves must be worn

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review, the facility failed to ensure separation of clean and soiled items, failed to store clean and soiled items properly and failed to ensure a clean environment to prevent cross-contamination and spread of infectious pathogens in the laundry department. Findings: 1. On 11/14/18 at 12:51 PM, an observation of the laundry area was conducted with the Administrator and the Director of Plant Operations. The soiled linen room, where all soiled resident linens are separated before being washed, revealed 4 floor buffer machines. One metal shelving unit contained 33 clean floor buffer pads and 21 clean cloth mop heads in an open box. A second metal shelving unit contained 14 plastic bags containing 2 clean pillows each for a total of 28 pillows. Multiple large plastic bags containing pillows were placed on top of the soiled plastic linen containers and 3 large bags with pillows were sitting on the floor next to the soiled plastic lined containers. The Director of Plant Operations stated, The buffer machines are used to clean resident's rooms and halls in the facility. They should not be stored in the room with the resident's soiled linens. On 11/14/18 at 1:07 PM, the Assistant Director of Nursing/Infection Control Nurse (ADON/ICN) and Administrator confirmed that nothing is to be stored in the soiled linen room due to cross contamination and spread of infection. 2. On 11/14/18 at 1:12 PM, an observation of the room containing the facility's 2 washing machines revealed an in-wall industrial fan. The metal safety cover was covered with multiple gray hanging substance and a lizard, not moving, was on the window ledge below the fan. The Director of Plant Operations confirmed that the fan in the washer room works, is dirty, is covered with gray dust and the lizard was dead. He said, I am not assigned to clean the fan. 3. On 11/14/18 at 1:17 PM, a white binder labeled Safety Data Sheets was in a metal basket attached to the wall approximately 12 inches from the washing machine. The ADON/ICN stated that the book has been exposed to the soiled linens going into the washer. Two boxes of medicated hand soap were observed on the floor in the clean linen folding room and clothing items were being stored on shelves up to the ceiling. The Director of Plant Operations stated that the room has an sprinkler and there can not be anything stored within 18 inches from the ceiling. 4. On 11/14/18 at 1:20 PM, a plastic bottle labeled Coke with clear fluid, a plastic bottle labeled Dasanti with clear fluid, and a red metal thermal insulated bottle with fluid were observed on the shelf above the clean linen folding table. The ADON/ICN, Director of Plant Operation and Administrator confirmed that nothing is to be stored on the floors and staff are not to be drinking in the clean linen room area. On 11/14/18 at 1:23 PM Laundry staff T stated that she has worked at the facility for approximately 1 year. That is my red container on the shelf. I am not supposed to be eating or drinking in the laundry area, but I don't know why not. 5. On 11/14/18 at 1:25 PM, a case of new towels with the white outer wrapping opened on both sides was observed on the floor under the clean laundry folding table. The Administrator and Director of Plant Operations confirmed that the new towels were not to be stored on the floor. Review of the Master Housekeeping and Laundry Service Agreement, dated February 1, 2017, read, Exhibit D Provide a safe, clean home-like environment Provide clean linen in good condition Review of the facility Infection Prevention and Control Program, dated June 2016, read, Policy: It is a policy of this facility to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections 10. Linens: a. Laundry and direct care staff shall handle, store, process, and transport linens so as to prevent spread of infection

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure newly hired, active and agency nursing staff were educated regarding clinical polices and procedures and evaluated for adequate competencies and skills to prevent unauthorized access to medication and treatment supplies on 1 of 2 units (North wing), and provide appropriate care and services for 6 of 55 sampled residents (#6, 34, 62, 72, 87 & 390). Findings: 1. On 11/14/18 at 9:15 AM, 2 unlocked storage cabinets and an unlocked treatment cart were observed on the North Wing. Both storage areas were well-stocked with central supply items such as hand sanitizer and barrier cream, and physician-prescribed ointments, creams, lotions and wound care supplies. At 9:18 AM, licensed practical nurse (LPN) P acknowledged she left the cart and cabinets unlocked. She explained she started wound treatments at about 8 AM that morning and retrieved supplies from the cart and cabinets and took them into residents' rooms. She stated she was not provided with keys for the cart or cabinets. LPN P explained a nurse on a medication cart had the key for the treatment cart and opened it for her. LPN P explained she worked for a nurse staffing agency and this was her second assignment in the facility. LPN P stated a nurse gave her instructions at the start of the shift, and described the process as very fast. She explained the instructions were quickly provided and not very detailed. LPN P did not recall any reviews of facility policy and procedures (P&Ps). On 11/14/18 at 9:44 AM, the North wing unit manager (UM) stated she usually did 1:1 training with agency nurses and certified nursing assistants (CNAs) at the start of their shifts. She explained she did not review LPN P's assigned tasks with her, but assumed she would secure the treatment cart and cabinets since it was standard nursing practice. However, the North wing UM confirmed she was aware LPN P did not have keys for either the treatment cart or the cabinet. 2. On 11/15/18 at 12:40 PM, LPN E provided wound care and applied a treatment to resident #62's sacral wound. She did not assess resident #62's pain level prior to starting the procedure and did not give pain medication in response to resident #62's complaints of pain during wound care. LPN E did not follow professional standards and the facility's P&P to avoid cross-contamination during the procedure. On 11/15/18 at 12:52 PM, LPN E stated she worked for a nurse staffing agency. She explained whenever she was called to a facility, it was usually an emergency or rush situation. She acknowledged she had never rounded with a wound physician as she was required to do that day, and had no specialized training in wound care. LPN E stated she was unsure of the requirements for rounding with the physician, and was not familiar with the residents' wounds. LPN E confirmed she was not familiar with the facility's process or the location of all necessary wound treatment supplies. On 11/16/18 at 3:07 PM, the assistant director of nursing (ADON) stated agency nurses usually did not do wound care. The ADON explained the facility employed a full time wound care nurse, who was currently on vacation. She stated education was provided verbally for new agency staff, followed by written education that would be signed by the nurse. The ADON acknowledged although LPN E was a nurse and therefore able to follow orders and do wound treatments, that particular assignment of rounds with the wound physician would have been more appropriate for the UM or a regular staff nurse. 3. On 11/16/18 at 8:58 AM, certified nursing assistant (CNA) M stated she had been on staff for about 6 months, and worked on an as needed (PRN) or part-time as needed basis. She was assigned to resident #72 who required extensive assistance of 2 staff members for transfers due to unsteady balance and left-side weakness. However, CNA M explained she transferred resident #72 between the bed and the wheelchair by herself. She stated she checked resident's care plans in a book kept at the nurses' station prior to giving care. The North wing UM interrupted and informed CNA M there was no book with that information, rather the facility used an electronic CNA care plan or [NAME]. CNA M acknowledged she was not aware the facility used an electronic [NAME], and stated she did not recall completing any training on use of the electronic [NAME]. 4. On 11/13/18 at 4:46 PM, registered nurse (RN) S gave medications to resident #87. Review of the medication administration record (MAR) revealed RN S gave medications that were scheduled to be given at 9 PM. RN S acknowledged she administered medications scheduled for later that shift in error. RN S acknowledged she did not check the scheduled administration time for all medications before she gave them to resident #87. In interviews conducted with the ADON, RN R and RN S on 11/16/18 from 3:09 PM to 4:38 PM, the ADON explained RN S was a new graduate nurse and worked under the supervision of RN R for a few days prior to being permitted to give medications on her own. She confirmed RN S's medication error occurred on her first unsupervised shift. The ADON acknowledged she was responsible for staff development and education, but did not recall reviewing the facility's P&P for medication administration with RN S. RN R informed the ADON she did not believe RN S was ready to work without supervision. RN S concurred, and stated she did not feel she should have been giving medications without supervision. The ADON stated a couple days prior to the medication error, she recalled RN R described the orientation period with RN S as going well. However, the ADON validated there was no orientation checklist to ensure nurses showed competence in all required tasks prior to working without direct supervision. 5. On 11/14/18 at 10:06 AM, during preparation of resident #34's scheduled morning medications, RN C included a tablet from a blister pack labeled with another resident's name and placed it in the pill cup. RN C acknowledged she did not adhere to the 5 rights of medication administration and check the name on the label prior to placing the pill in the cup. 6. Observations of resident #390 on 11/15/18 during the 7 AM to 3 PM shift revealed he had a urinary drainage bag with very dark amber urine and an extremely foul odor. During the shift, at 12:08 PM, CNA D stated she noticed the appearance and odor of resident #390's urine and informed RN C that morning. She stated RN C entered the room and observed the urine. At 2:31 PM, RN C confirmed CNA D reported concerns regarding resident #390's urine and acknowledged she did not follow-up appropriately. RN C said, I should have checked the tube output and called the physician. It could be an infection. 7. On 11/13/18 at 12:11 PM, during observation of lunch meal service on the South wing, CNA Q assisted resident #6. She buttered his roll while she held it with her bare hand. CNA Q stated that she worked at the facility for over 2 months, and no one had ever told her any other way to butter a resident's roll. On 11/16/18 at 3:25 PM, the ADON explained the Human Resources (HR) department reviewed facility P&Ps with all new employees, then nursing staff received further orientation on the units. She stated she educated agency nurses and had them sign off as confirmation of education. The ADON confirmed the facility did not have a standardized performance appraisal process to evaluate new hires or current employees. She explained there was no requirement or process in place for nursing staff to demonstrate competency in required skills. On 11/16/18 at 3:40 PM, the facility's HR manager stated she was responsible for new employees' pre-hire paperwork, and on their start dates, she reviewed HR policies and the corporate handbook. In contrast to the ADON's statement, the HR manager clarified she did not review any clinical P&Ps with new hire nurses. She explained nurses received their orientation on the units, and did assigned online classes and training. The HR manager stated RN C was hired about 6 weeks ago, and RN S was hired about 1 week ago. She was not able to provide transcripts with proof of completion of mandatory training prior to unsupervised interactions with residents. On 11/16/18 at 5:23 PM, the ADON confirmed neither RN C nor RN S had enrolled in any of the required online classes, including Medication Administration. Review of in-service attendance sheets revealed an in-service on medication administration given on 11/13/18 was attended by 10 of the facility's 31 nurses, and an in-service on food handling dated 11/13/18 was attended by 19 of 85 members of the nursing department. Review of attendance sheets provided by the ADON for in-services on code status (undated), dialysis communication (11/13/18), isolation precautions (10/25/18), smoking assessments (11/13/18), narcotic management (10/29/18), revealed less than 50% of the appropriate nursing staff were educated. The attendance sheet for food handling did not include a signature for CNA Q. The facility was not able to provide documentation of testing or evaluation of competencies related to the education provided. Review of the Facility Assessment, revised 11/01/18, detailed the facility resources needed to provide competent support and care for residents. The document specified mandatory staff education and competency requirements .that are necessary to provide the level and types of support and care needed The competencies included the areas of activities of daily living care, infection control, medication administration, resident assessment and evaluation and specialized care such as catheter care and wound dressings. The Facility Assessment did not include information on the method(s) the facility would use to evaluate competencies and validate knowledge and proficiency of nursing staff.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Administration (Tag F0835)

Could have caused harm · This affected multiple residents

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Based on record review and interview, the facility failed to effectively administer its resources to maintain a safe, clean and homelike environment, and failed to evaluate and ensure competency of nursing staff to meet the needs of residents. Findings: Cross reference: F558, F584, F686, F690, F726, F759, F761 and F812 Review of the job descriptions for the Director of Nursing (DON) and Assistant Director of Nursing (ADON) revealed administrative functions including developing, evaluating and directing the nursing department. He/she was expected to assist in evaluating nursing personnel and ensure nursing staff were .performing duties in accordance with acceptable nursing standards The DON and ADON had staff development roles that included developing and implementing training and in-services for nursing staff. Review of the job description for the Nursing Home Administrator revealed he/she was responsible To direct the day-to-day functions of the facility to ensure that the highest degree of quality care can be provided to the residents at all times. The administrator was expected to ensure all facility employees complied with all policies and procedures (P&P) and identify problems and deficiencies His/her staff development duties included assisting with .planning, developing, conducting and scheduling orientation, in-service training, on-the-job training and other educational activities for personnel to ensure that current materials and programs are continuously provided. The administrator's duties also required that he/she would ensure the facility was maintained in good repair. On 11/16/18 from 2:59 PM to 3:25 PM, the ADON stated department managers were assigned to do room rounds every morning and were expected to provide the results to the administrator every day. However, she explained managers did not always comply, and acknowledged they required education since they were apparently not identifying environmental concerns. The ADON stated to her knowledge, newly hired nurses reviewed all facility policies and procedures (P&Ps) with the Human Resources (HR) Manager on hire. She explained new nursing staff then shadowed staff on the units, and were also expected to do mandatory online training. She stated agency nurses should be educated before their shifts. The ADON acknowledged the facility did not currently have an organized and consistent system to ensure nursing staff received all the mandatory education and demonstrated competencies prior to providing care and services for residents. In addition, she confirmed the facility did not have a standardized performance appraisal process to regularly evaluate competencies of active employees at regular intervals. On 11/16/18 at 3:40 PM, the HR Manager acknowledged she met with newly hired employees on their first day. However, in contrast to the ADON's statement, the HR Manager explained she reviewed the corporate handbook and only mandatory HR policies, such as abuse and residents' rights, with new employees. The HR Manager stated she was not involved in organizing or scheduling any additional orientation for clinical staff. On 11/16/18 at 4:18 PM, the administrator confirmed he was responsible for oversight of the new employee hiring process. He explained there should be a 2-day orientation for all new employees. The administrator acknowledged he was not aware newly hired nurses were not receiving a 2-day orientation nor being educated with the facility's clinical P&Ps. He acknowledged responsibility for oversight of the room rounds process and stated he did occasional audits of daily room rounds checklists, but performed regular inspections of the common areas only. The administrator validated there was lack of effective communication between administration and other departments.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• No fines on record. Clean compliance history, better than most Florida facilities.

Concerns

• 21 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
• Grade C (55/100). Below average facility with significant concerns.

Bottom line: Mixed indicators with Trust Score of 55/100. Visit in person and ask pointed questions.

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About This Facility

What is Avante At Orlando Inc's CMS Rating?

CMS assigns AVANTE AT ORLANDO INC an overall rating of 3 out of 5 stars, which is considered average nationally. Within Florida, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.

How is Avante At Orlando Inc Staffed?

Detailed staffing data for AVANTE AT ORLANDO INC is not available in the current CMS dataset.

What Have Inspectors Found at Avante At Orlando Inc?

State health inspectors documented 21 deficiencies at AVANTE AT ORLANDO INC during 2018 to 2021. These included: 1 that caused actual resident harm and 20 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.

Who Owns and Operates Avante At Orlando Inc?

AVANTE AT ORLANDO INC is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by AVANTE CENTERS, a chain that manages multiple nursing homes. With 118 certified beds and approximately 0 residents (about 0% occupancy), it is a mid-sized facility located in ORLANDO, Florida.

How Does Avante At Orlando Inc Compare to Other Florida Nursing Homes?

Compared to the 100 nursing homes in Florida, AVANTE AT ORLANDO INC's overall rating (3 stars) is below the state average of 3.2 and health inspection rating (3 stars) is at the national benchmark.

What Should Families Ask When Visiting Avante At Orlando Inc?

Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"

Is Avante At Orlando Inc Safe?

Based on CMS inspection data, AVANTE AT ORLANDO INC has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #100 of 100 nursing homes in Florida. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Avante At Orlando Inc Stick Around?

AVANTE AT ORLANDO INC has not reported staff turnover data to CMS. Staff turnover matters because consistent caregivers learn residents' individual needs, medications, and preferences. When staff frequently change, this institutional knowledge is lost. Families should ask the facility directly about their staff retention rates and average employee tenure.

Was Avante At Orlando Inc Ever Fined?

AVANTE AT ORLANDO INC has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.

Is Avante At Orlando Inc on Any Federal Watch List?

AVANTE AT ORLANDO INC is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Facility Details

Beds: 118
Avg. Residents: 0
Occupancy: N/A
Ownership: For profit - Corporation
Chain: AVANTE CENTERS
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
3-Star Rating: +20
1 Actual Harm citation: -5
21 Deficiencies: -10
Final Score: 55/100

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Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 106027