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Inspection visit

Inspection

AVANTE AT MT DORA, INCCMS #1053331 citation on this visit
1 citation recorded

Inspector’s narrative

What the inspector wrote

This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

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 (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 105333 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at MT Dora, Inc 3050 Brown Ave Mount Dora, FL 32757 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
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 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105333 If continuation sheet Page 2 of 2

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Citations

1 citation recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0770GeneralS&S Dpotential for harm

    F770 - Laboratory Services

    Provide timely, quality laboratory services/tests to meet the needs of residents.

FAQ · About this visit

Common questions about this visit

What happened during the September 10, 2025 survey of AVANTE AT MT DORA, INC?

This was a inspection survey of AVANTE AT MT DORA, INC on September 10, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at AVANTE AT MT DORA, INC on September 10, 2025?

Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Provide timely, quality laboratory services/tests to meet the needs of residents."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.