Inspection·May 5, 2023

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to thoroughly investigate an injury of unknown origin for 1 of 1 resident reviewed for neglect from a total sample of 3 residents, (#1). Residents Affected - Few Findings: Review of the medical record revealed resident #1 was admitted to the facility on [DATE] and readmitted from an acute care hospital on 6/17/2022. The nursing, Progress Notes dated 4/26/2023 noted the resident had contusions to her left eye and left arm/shoulder. The resident was transported to the emergency room and returned to the facility the same day with diagnoses of hematoma around her left eye, and multiple contusions. On 4/30/2023, the resident sustained a fall from her wheelchair resulting in bleeding from her nose and required medical transport to the emergency room where she was admitted to the hospital. The Minimum Data Set annual assessment with Assessment Reference Date 2/15/2023 noted the resident scored 1 out of 15 on the Brief Interview for Mental Status Exam, which indicated the resident was severely cognitively impaired. The resident had no behavioral symptoms or rejections of evaluation or care for health and wellbeing. The assessment showed resident #1 required extensive staff assistance for activities of daily living and had 1 fall since the prior assessment. On 5/04/2023 at 2:57 PM, the Director of Operations explained the facility began an investigation on 4/26/23 into resident #1's injuries that nursing staff reported they had observed the same day. She said witness statements were provided from nurses, Certified Nursing Assistants (CNA), and a Patient Care Attendant (PCA) who had been assigned to the resident and those working on the same unit. Review of the statement from CNA B noted the resident had not sustained a fall. The statement received from PCA A noted the resident sustained a fall on 4/25/2023 and he assisted CNA B with getting the resident off the floor and into her bed. On 5/4/2023 at 3:12 PM, the Director of Nursing (DON) said she obtained statements by telephone from PCA A and CNA B on 4/26/2023. She explained she was concerned because the statements were contradictory. She stated she provided education to both staff during the telephone call about reporting falls. On 5/4/2023 at 3:15 PM, the DON provided an unsigned statement from PCA A that was undated. She said she wrote the date 4/25/2023 on the form to indicate the date of the incident. She explained she completed the form during her telephone call with PCA A on 4/26/2023. The statement showed PCA A said, no fall or injuries during my time. The DON provided an additional unsigned statement that she explained was handwritten by PCA A. The form was dated 4/27/2023 and noted on 4/25/2023, CNA B (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: 105671 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 105671 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at Melbourne Inc 1420 South Oak Street Melbourne, FL 32901 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)