Avante at Leesburg, Inc

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain food service equipment and food storage areas in a clean and sanitary condition by failing to ensure the kitchen ice machine and 2 of 2 nourishment room refrigerators and freezers were maintained free of debris and contamination. During an observation of the main kitchen on 07/19/2026 at 9:17 AM, the ice machine was observed with a significant amount of black substance and brown colored substance on the dispensing spout where ice falls into the storage bin. (Photographic evidence was obtained.)During observations of the facility nourishment rooms on 07/19/2026, the refrigerators and freezers in both rooms were observed to contain food debris and spilled liquid on interior surfaces. On 07/19/2026 at 10:13 AM, the Administrator and Director of Nursing confirmed the condition of the ice machine. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for 2 of 7 residents reviewed (Residents #2 and #73).

Inspectors wroteBased on record review and interview, the facility failed to ensure residents with newly evident or known diagnosis of serious mental disorders have a coordinated Preadmission Screening and Resident Review (PASRR) for 3 of 7 residents, Residents #4, #11, #36 reviewed for PASRR.

Inspectors wroteBased on record review and interview, the facility failed to ensure the completion of the Preadmission Screening and Resident Review (PASRR) prior to admission for a resident's serious mental disorder for 1 of 7 residents, Resident #107, reviewed for PASRR.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive care plan for 1 of 5 residents, Resident #3 reviewed for diabetes management.

Inspectors wroteBased on observation, interview and record review the facility failed to administered pain medication based on parameters for 1 of 6 residents, Resident #107, reviewed for medication management and failed to provide dressing changes for 1 of 3 residents, Resident #3, reviewed for skin conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible for 21 residents currently residing in the facility's Memory Care Unit. During an observation on 07/19/26 at 09:35 AM, an uncapped safety razor was observed at Resident #43's bedside on the nightstand [photographic evidence obtained]. Resident #43 resides in the Memory Care Unit, and the bedroom door was not secure from the outside. During an interview on 07/19/26 11:38 AM, Staff F, Registered Nurse, stated that residents should not keep safety razors in their rooms. [Resident #43's Name] is supervised while shaving because he has the functional ability to do so, but it must have been left with him. She stated, That's not supposed to be there. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide oxygen at the prescribed rate for 1 Resident (Resident #33) and store oxygen supplies appropriately when not in use for 3 of 6 residents, Residents #2, #28, and #33, reviewed for respiratory services.

Inspectors wroteBased on interview and record review the facility failed to collect laboratory exams ordered by the physician for 1 of 2 residents, Resident #15 reviewed for laboratory services.

Inspectors wroteBased on record review and interview, the facility failed to maintain complete and accurate clinical records for 13 (Resident #2, 6, 11, 17, 18, 25, 29, 39, 45, 56, 59, 66 and 104) out of 19 Residents, reviewed for medication orders and administration documentation.

Inspectors wroteBased on observation, interview and record review the facility failed to follow prevent the spread of potential infectious diseases by not performing hand hygiene and following sterile procedure for 1 of 3 residents, Resident #33, reviewed for tracheostomy care, failed to follow enhanced barrier precautions in 1 of 3 units , and failed to contain soiled linen in the soiled utility room in the laundry room.

Inspectors wroteBased on observation, record review, and interview, the facility failed to implement its smoking policies and procedures to ensure smoking materials were maintained by nursing staff for 1 of 3 residents reviewed for smoking safety (Resident #74).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe, clean, comfortable and homelike environment for residents in 2 of 3 units for 5 residents, Residents #2, #4, #8, #9, and #10, reviewed for homelike environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure the provider was notified when a resident left the facility against medical advice for 1 of 3 residents, Resident #3, reviewed for change in condition.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure respiratory care and services were provided in accordance with professional standards of practice for 3 (Resident #195, #82, and #36) of 6 residents reviewed for oxygen therapy and respiratory treatments.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure food was safely stored, dated in a manner that preserves the nutritional value, and sanitation was maintained in the kitchen.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure resident assessment accurately reflects the resident's status for 2 (Resident #2, #14) of 7 residents reviewed for nutrition and dialysis.

Inspectors wroteBased on interview and record review the facility failed to ensure Preadmission Screening and Resident Review (PASRR) was accurately completed for 3 (Resident #55, #66, #70, ) of 7 residents reviewed for mood and behavior

Inspectors wroteBased on observation, interviews and record review, the facility failed to develop and implement a comprehensive care plan for 1 (Resident #70) of 6 resident reviewed for medication management and 1 (Resident #42) of 6 residents reviewed for Hospice.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure care and treatment was provided in accordance with professional standards of practice for 2 (Resident #84, #395) of 8 residents reviewed for central venous access devices and skin conditions.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure physician ordered laboratory services were completed for 1 (Resident #59) of 6 residents reviewed for medication regimen.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to maintain complete and accurately documented medical records for 3 (Resident #84, #395, and #70) of 12 residents reviewed for skin conditions and medication management.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure and maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment and to prevent the possible development and transmission of communicable diseases and infections for 3 (Resident #248, #246 and #68) of 7 residents for personal protective equipment, transmission based precautions, and tracheostomy care and 1 of 4 hallways for a sanitary environment.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents received services as ordered by physician for 1 of 3 sampled residents, Resident #1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was not 5 percent or greater. The medication error rate was 20 percent.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the drugs and biologicals were stored and labeled in accordance with currently accepted professional principles in 3 of 4 medication carts and failed to ensure medications were secured in 1 resident room, Resident #94.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents received care and services in accordance with professional standards of practice for 1 of 4 residents with gastrostomy tubes (GT), Resident #42.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure staff performed hand hygiene during medication administration to help prevent the possible spread of infection and communicable diseases.