Health inspection·September 10, 2025

F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to report the laboratory results to the physician in a timely manner in accordance with professional standards of practice for 1 of 3 residents reviewed for hospital transfers (Resident 1).Findings include:Review of Resident #1's admission record showed the resident was most recently admitted on [DATE] with the diagnoses including right dominant side hemiplegia, acute kidney failure, dementia, cognitive communication deficit, type 2 diabetes mellitus, pulmonary fibrosis, edema, and failure to thrive.Review of Resident #1's laboratory results showed the first partial result on 7/2/2025 at 1:17 PM and the second partial result on 7/2/2025 at 1:37 PM, and the final result on 7/2/2025 at 1:42 PM. The reports showed abnormal BUN (Blood Urea Nitrogen; a blood test that measures the amount of urea in the blood, primarily to assess kidney function) result of 90 H (high), with the normal range being 8-27 mg/dL (milligram/deciliter); abnormal Creatinine (waste product from normal muscle and protein breakdown, released into the bloodstream and filtered by the kidneys into urine.) result of 3.9 H, with normal range being 0.5-0.9 mg/dL.Review of Resident #1's daily progress notes for 7/2/2025, 7/3/2025, and 7/4/2025 showed no documentation of laboratory results being reported to physician.Review of Resident #1's physician progress note dated 7/2/2025 showed it read, History of Present Illness: General: 74 yo [years old] with medical h/o [history of] DM2 [type 2 diabetes mellitus]/Neuropathy, Fibromyalgia, HTN [hypertension], HLD [hyperlipidemia], CVA [cerebrovascular accident] with residual hemiplegia, cognitive communication deficient, was recently hospitalized due to AKI [Acute Kidney Injury], Weakness, FIT [Failure to Thrive]. Treated and stabilized at hospital. Transferred to this facility to continue medical treatment and skilled rehabilitation. Patient is being seen today for follow up and review management. At evaluation, pt [patient] is alert and oriented in person, in no distress. Denies chest pain, no SOB [Shortness of Breath], no nausea or vomiting, no abdominal pain. No pain at evaluation. Generalized weakness more left side hemibody. PT/OT/ST [Physical Therapy/ Occupational Therapy/ Speech Therapy] to evaluate and treat. Assist with ADLs [Activities of Daily Living]. Falls precautions.During a telephone interview on 9/10/2025 at 3:00 PM, the Physician stated, I do not recall a call for her [Resident #1] results. I saw the patient that day and only that day. As per my routine when in the facility, I visit new admission first thing in the morning, then continue to see others in the facility. Lab result from any day will start coming in around 2 PM. The result should have been reported to me that day.During an interview on 9/10/2025 at 2:13 PM, the Director of Nursing (DON) stated, The labs results should have been reported to the physician immediately.Review of the facility policy and procedure titled Diagnostic Services revised on 3/2/2019 showed it read, Policy: It is the policy of this facility to ensure that laboratory, radiology, and other diagnostic services meet the needs of residents, that results are reported promptly to the ordering provider to address potential concerns and for disease prevention, provide for resident assessment, diagnosis, and treatment, and that the facility has established policies and Residents Affected - Few Page 1 of 2 105333 105333 09/10/2025 Avante at MT Dora, Inc 3050 Brown Ave Mount Dora, FL 32757

F 0770 Level of Harm - Minimal harm or potential for actual harm procedures, and is responsible for the quality and timeliness of services whether services are provided by the facility or an outside resource. Procedure: 4. The facility will promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside of the clinical reference ranges in accordance with the facility policies and procedures for notification of a practitioner or per the ordering physician's orders. Residents Affected - Few 105333 Page 2 of 2