Avante Rehabilitation Center

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 1 resident (Resident #1) of 2 residents reviewed for infection control. The facility failed to ensure LVN A performed hand hygiene and changed gloves during wound care for Resident #1 on 4/23/2026. This failure could place residents at risk for infection and cross contamination. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure it was free of a medication rate of five percent (5%) or greater. There were three medication errors observed out of 31 opportunities resulting in an 9% medication error rate. One (LVN B) of two staff observed made two errors during the medication pass for one (Resident #81) of two residents observed. 1. LVN B on 07/29/2025 administered Resident #81 MiraLAX Oral powder 17grm (for constipation) without the appropriate amount of fluid. 2. LVN B on 07/29/2025 failed to administer Advair HFA Inhalation Aerosol 115-21 mcg to Resident #81. 3. LVN B on 07/29/2025 failed to administer Isosorbide Mononitrate ER oral tablets 60mg to Resident #81. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety. 1. The facility failed to ensure food items in the freezer were stored sealed and not exposed to air in accordance with the professional standards for food service.2. The facility failed to ensure food items in the refrigerators and freezer were labeled with the item description (handwritten or manufacturer's label), had the received by date, the opened date and/or the consume by or expiration by dates. These failures could place residents at risk for food-borne illness and cross contamination. [...]

Inspectors wroteBased on interview and record review the facility failed to assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months for review for 1 of 5 residents (Resident #6) reviewed for assessments. The facility failed to complete a quarterly assessment for Resident #1 every 3 months since [DATE]. This failure could place residents at risk for not getting an accurate assessment and could result in lack of care.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen. The facility failed to maintain quat sanitizer at a proper level in all three sanitation buckets, having levels of 500 ppm, and sanitation compartment of the three-compartment sink having level of 400 ppm. The facility failed to maintain the chlorine at a proper level in the dishwasher sanitizer cycle, having a level of 200 ppm. These failures could place all residents who eat off facility dishes at risk for exposure to higher than necessary levels of sanitizer chemicals, potentially leading to irritation of the digestive tract, and intestinal symptoms. Findings Included: [...]

Inspectors wroteBased on interview and record review the facility failed to submit discharge MDS assessments for five of fifteen residents (Residents #2, #37, #45, #80, and #82) reviewed for discharge MDS submission. The MDS Coordinator failed to successfully submit discharge MDS assessments Residents #2, #37, #45, #80, and #82 when they discharged from the facility. This failure could place residents at risk of communication about a resident's status from not being transmitted to CMS and could interfere with residents receiving needed services after discharge.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 8.57 % based on 3 errors out of 35 opportunities, which involved 3 of 9 residents (Resident #9, Resident #35, and Resident #46) reviewed for medication errors. The facility failed to ensure MA C and ADON B administered Resident #9's external pain reliving patch to her right lateral (directional term describing outer side of the body part) hip as ordered by the physician. The facility failed to ensure MA C administered Resident #35's antibiotic eye ointment only in the left eye as ordered by the physician. The facility failed to ensure Resident #46 received his daily Vitamin D tablet as prescribed on 07/31/24. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to 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 for 4 (Residents #20, #46, #78 and #83) of 9 residents reviewed for infection control. The facility failed to ensure MA D sanitized blood pressure cuff between use on Residents #20, #46, and Resident #83. The facility failed to implement an infection control and prevention plan that included gastronomy care (G-tube- resident received food through a tube into his stomach) for Resident #78. These failures could place residents at risk of cross contamination and infectious diseases.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received an accurate assessment, reflective of the resident's status for one (Resident #73) 24 residents reviewed for accuracy of assessments. The facility failed to ensure Resident #73's Significant Change MDS Assessment, dated 06/18/24, did not inaccurately reflect Resident #73 having had a tracheostomy (a surgical opening in the windpipe to allow air into the lungs). This failure could place residents at risk for not receiving care and services to meet their needs, diminished function of health, and regressions in their overall health.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure basic life support, including cardiopulmonary resuscitation (CPR), was provided to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for one (Resident #1) of three residents reviewed for CPR. [...]

Inspectors wroteBased on interviews and record review, the facility failed to notify and consult with the resident's physician of a significant change in the resident's physical, mental, or psychosocial status that is, a deterioration in health, mental, or psychosocial status for one (Resident #1) of one resident reviewed for notification of changes. The facility failed to ensure LVN B immediately notified the physician on 08/14/23 when Resident #1 had an elevated temperature of 100.3 F and N/V brownish partially digested food. The facility failed to ensure LVN A notified the physician on 08/15/23 that Resident #1's laboratory results were released to the facility on [DATE] at 12:55 PM. On 08/16/23 at 1:23 PM, the NP reviewed labs in PCC. Labs resulted WBC 22. UA with many bacteria, dehydration, and UTI. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from neglect for 1 of 1 resident (Resident #1) reviewed for neglect. The facility failed to ensure LVN A and LVN B did not neglect Resident #1. They failed to implement nursing interventions as written in Resident #1's care plan. LVN B failed to immediately contact the physician when Resident #1 had an acute change in condition. LVN A failed to immediately contact the physician of abnormal labs results, which indicated infection and dehydration, when received. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to develop and implement written policies and procedures that prohibit and prevent neglect for 1 of 1 resident (Resident #1) reviewed for provision of care and services by staff. The facility failed to oversee the implementation of required structures and processes to meet the needs of Resident #1. The facility failed to oversee LVN A and LVN B followed resident care policies and procedures during the provision of care and services to Resident #1. The facility failed to conduct ongoing monitoring and supervision of LVN A and LVN B to assure the implementation of Resident #1's care plan as written. The facility failed to ensure there was an effective communication system across all shifts for communicating necessary care and information between staff, practitioner, and resident representatives. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident with urinary incontinence, based on the resident's comprehensive assessment, who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary and a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for one (Resident #1) of five residents reviewed for Urinary Tract Infection (UTI). On 08/10/23 Resident #1's FC was discontinued after unknown nurse reported leakage. The facility failed to ensure LVN B immediately notified the physician on 08/14/23 when Resident #1 had an elevated temperature of 100.3 F and N/V brownish partially digested food. [...]

Inspectors wroteBased on interviews and record review, the facility failed to promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside of clinical reference ranges for one (Resident #1) of five residents reviewed for Laboratory Services. The facility failed to ensure LVN A notified the physician on 08/15/23 that Resident #1's laboratory results were released to the facility on [DATE] at 12:55 PM. On 08/16/23 at 1:23 PM, the NP reviewed labs in PCC. Labs resulted WBC 22. UA with many bacteria, dehydration, and UTI. An Immediate Jeopardy (IJ) was identified on 10/02/23. The IJ template was provided to the facility on [DATE] at 5:20 PM. [...]

Inspectors wroteBased on interview and record review, the facility failed to within 14 days after a facility completed a resident's assessment, electronically transmit encoded, accurate, and complete MDS data to the CMS system for three (Residents #23, #36 and #88) of eight residents reviewed for resident assessments. The facility failed to ensure Residents #23, #36, #88's MDS discharge assessments was transmitted within 14 days after they discharged this facility. This failure could affect discharged residents from getting the appropriate continuity of care with other healthcare providers in the community or other Nursing facilities if they continued to appear to be a resident at this facility which could cause a decline in benefits and affect the facility's census statistics in the CMS database.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records on each resident that were complete and accurately documented for four (Residents #23, #36, #54 and #88) of eight residents reviewed for Medical records. 1. The facility failed to ensure Residents #23, #36, #88's MDS discharge assessments were completed and in their medical records after they discharged this facility. 2 The facility failed to have accurate 14 day admission and Quarterly MDS Assessments completed for Resident #54, since she re-admitted [DATE]. These failures could cause all residents to be at risk of inadequate care if inaccurate diagnoses or missing documentation were not included in their medical records, resulting in not properly assessing, monitoring and treating a resident and causing them distress, pain and decreased psycho-social well- being.

Inspectors wroteBased on observation, interview, and record review, the facility failed ensure assessments accurately reflected the resident's status for one (Resident #54) of eight residents reviewed for resident assessments. The facility failed to do Resident #54's admission and Quarterly MDS assessments, despite her being a private pay resident.

Inspectors wroteBased on interview and record review, the facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for two (Resident #7 and Resident #72) of three residents reviewed. The facility failed to implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality for Resident #7 and Resident # 72. [...]