Avante at Ocala, Inc

Inspectors wroteBased on observation, interview and record review the facility failed to keep 1 Resident (Resident #3) out of 3 Residents sampled receives the necessary services to maintain good grooming in keeping fingernails clean and trimmed.

Inspectors wroteBased on record review and interview, the facility failed to ensure 1 Resident (Resident #1) out of 3 Residents sampled receives necessary treatment and services for pressure sores consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

Inspectors wroteBased on interview and record review, the facility failed to ensure the individual responsible for directing the dietary service met the required qualifications in accordance with regulatory requirements affecting all residents receiving dietary services by increasing the risk of inadequate nutritional management, improper food safety practices, and noncompliance with dietary regulations.

Inspectors wroteBased on interview, record review, and review of policies and procedures, the facility administration failed to administer the facility in a manner that enables it to use its resources effectively and efficiently to attain and maintain the highest practicable physical wellbeing of each resident by failing to fully implement performance improvement plans for identified non-compliance related to Preadmission Screening and Resident Review, medication storage, medication administration errors, wound care, and infection control.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the full implementation of the facility's developed performance improvement plans to correct the facility's identified quality deficiencies for wound management, medication administration, infection control, and preadmission screening.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a homelike environment for resident access to accommodate room lighting on 3 of 3 hallways and failed to ensure all telephones and window blind mechanisms were in working order.

Inspectors wroteBased on interview and record review the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) was accurate for 3 of 4 residents, Residents #2, #11, and #28, assessed for accuracy of PASRR.Findings Include: 1) Review of Resident #11's clinical record documented the resident was admitted on [DATE] with a diagnosis to include adjustment disorder with depressed mood. Review of Resident #1's State of Florida Agency for Health Care Administration Preadmission Screening and Resident Review (PASARR) dated 10/22/2025 did not document any mental illness. [...]

Inspectors wroteBased on record review, observation, and staff interviews, the facility failed to ensure sufficient nursing staff and an effective staffing system was in place to meet resident needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean and sanitary kitchen environment, increasing the risk of contamination, foodborne illness, and infection.

Inspectors wroteBased on interview and record review the facility failed to encode and transmit the resident discharge assessment for 1 of 3 residents, Resident #136, reviewed for minimum data set [MDS] completion.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident assessments were accurate and reflected the resident's current status for 3 of 12 residents, Residents #17, #50, and #152, reviewed for Minimum Data Set (MDS) accuracy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and/or implement a comprehensive, person-centered care plan for 3 of 12 residents, Residents #8, #17, and #28, reviewed for comprehensive, person-centered care plans. Findings Include: 1) During an observation on 3/23/2026 at 9:30 AM Resident #8 was sleeping and did respond to being addressed by name. Resident was dressed and lying in bed covered with a blanket. The head of the bed was elevated. During an interview on 3/23/2026 at 4:30 PM the Director of Nursing (DON) stated, She [Resident #8] is on hospice. A request was made to review Resident #8's care plan for hospice. The DON said the resident stated she did not want hospice and then wanted hospice. [Resident #8's name] should have an order for hospice and have a care plan for hospice. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure assistance with activities of daily living (ADLs) for nail care for 1 of 6 residents, Resident #86, reviewed for ADL care.

Inspectors wroteBased on observation, interview, and record review the facility failed to obtain the medication dosage prior to administration for 1 of 3 residents, Resident #84, and failed to ensure wound care treatment orders and wound care for 1 of 3 residents, Resident #157, observed for wounds.

Inspectors wroteBased on observation, interview and record review the facility staff failed to ensure that nebulizer mask stored after use consistent with professional standards of practice for 2 residents( Resident # 84 and Resident #121) of 6 Residents reviewed for respiratory care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was not five percent or greater for 2 out of 37 observations. The facility had a medication error rate of 5.41%.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs were secured and/or not expired in accordance with professional standards for 2 of 3 units, for Residents #28, #155, #156, residents observed with unsecured and/or expired medications, not securing medications when unattended for 1 of 5 medication carts, and expired medications for 2 of 5 medication carts.

Inspectors wroteBased on record review and interview, the facility failed to ensure resident records were complete and accurate for 5 of 8 residents, Residents #11, #12, #14, #49, and #77, reviewed for medical records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene during medication administration, failed to ensure staff sanitized enteral medication flush syringe, failed to ensure an infection control barrier was provided in the laundry room, and failed to ensure staff used appropriate PPE (Personal Protective Equipment) for the residents on transmission based precautions to prevent the possible spread of infection and communicable diseases.

Inspectors wroteBased on interview and record review, the facility failed to implement care plan interventions related to management of a metabolic condition/concern related to hypokalemia for 1 (Resident #4) of 3 residents reviewed for nutritional services and failed develop a care plan to address 1 (Resident #1) of 3 with a diagnosis of post traumatic stress disorder reviewed for behavioral health.

Inspectors wroteBased on interviews and observations, the facility failed to ensure sufficient clean linen, washcloths, towels, and protective bed pads, to meet the care needs of residents

Inspectors wroteBased on interviews, observations, and policy and procedure review the facility failed to ensure snacks were offered and/or served to 5 of 5 residents, Residents #1, #2, #3, #4, and #5, sampled for evening snacks.

Inspectors wroteBased on interview and record review the facility failed to ensure residents medical records were complete and accurate for 1 of 3 residents, Resident #1, reviewed for mood and behaviors.

Inspectors wroteBased on record review and interview, the facility failed to ensure an accurate Level I Preadmission Screening and Resident Review (PASRR) screen was completed for 1 of 2 residents who were diagnosed with serious mental disorder, Resident #58.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents received treatment and care according to professional standard of practice by administering narcotic pain medication out of parameters for 2 of 3 residents reviewed, Residents #73 and #318.

Inspectors wrote2) During an observation on 10/14/2024 at 10:17 AM, Resident #8 was lying in bed watching television. There was one tube of Diclofenac Sodium gel in a plastic bin on the resident's overbed table. During an observation on 10/15/2024 at 8:15 AM, Resident #8 was lying in bed sleeping. There was one tube of Diclofenac Sodium gel in a plastic bin on her overbed table. During an interview on 10/15/2024 at 11:19 AM, Resident #8 stated, I keep the gel there all the time because I use it a lot. Review of Resident #8's physician order dated 10/8/2024 read, [Brand Name of Product] (Diclofenac Sodium) Topical, Apply to affected area topically every day and evening shift for pain. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was safely stored, covered, labeled, or discarded in the areas of the kitchen and reach-in coolers (Photographic evidence obtained).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff used proper personal protective equipment while providing high contact care to the residents on Enhanced Barrier Precautions to prevent the possible spread of infection and communicable diseases.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the assessment accurately reflects the resident's status for 2 of 3 residents, Residents #38 and #121.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident who was diagnosed with a serious mental illness received re-admission screening and resident review (PASARR) to ensure the resident receives care and services in the most appropriate setting for 1 of 3 residents, Resident #23 for PASARR.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide care and services for central venous access devices in accordance with professional standards of practice for 1 of 3 residents, Resident #174, and for treatment and care of contractures for 1 of 3 residents, Residents #92.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received respiratory care services consistent with professional standards of practice for 2 of 4 residents, Residents #84 and #95.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure all drugs and biologicals were stored in locked compartments to permit only authorized personnel to have access for 1 of 3 hallways, the South Unit.