Inspection visit
Inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room,
etc.) that affect the resident.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, and record review, the facility failed to ensure the resident's representative was notified of a
change in condition pertaining to multiple falls for 1 of 2 residents reviewed for falls of a total sample of 6
residents, (#1).
Findings:
Resident #1 was admitted to the facility on [DATE] with diagnoses of spinal stenosis lumbar region, lack of
coordination, intervertebral disc degeneration, dementia, Chronic Obstructive Pulmonary Disease, cognitive
communication disorder, Diabetes type II, repeated falls, and pain.
Review of the resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date
of 11/15/23 revealed the resident's cognition was severely impaired with a Brief Interview For Mental Status
(BIMS) score of 07 out of 15. The assessment revealed the resident required supervision or touching
assistance for toilet transfers, chair/bed-to-chair transfers, sit to stand, and walking. The assessment noted
the resident had two or more falls since his admission or prior assessment.
Review of the facility's SBAR (Situation, Background, Appearance, Review and Notify) Communication
Form and nursing Progress Notes revealed the resident had falls on 11/05/23, 11/18/23, 12/10/23, and
12/12/23. The documentation noted, name of family/Health Care Agent notified read, resident is his own
responsible party).
On 1/09/24 at 12:27 PM, in a telephone interview, the resident's wife stated she was the person to be
contacted if there was a change in the resident's condition. She said she expected to be called, but the
facility had not called her for all the resident's falls. She stated that when she visited, she noticed her
husband had bruises. She explained her husband's roommate told her he fell. She could not recall the
roommate's name, and stated the resident had several roommates since his admission.
On 1/09/24 at 3:44 PM the Regional Director of Clinical Services (RDCS) stated the facility's Risk
Management documentation was privileged and confidential and could not be shared. The RDCS noted the
resident's family was notified of the falls on 11/05/23, and 11/18/23. Review of the documentation on the
SBAR form for falls on 11/05/23, 11/18/23, 12/10/23, and 12/12/23 showed the resident was his own
responsible party and there was no evidence his wife was informed. The RDCS stated no additional
documentation regarding the resident's falls, and notification of the resident's wife listed as his emergency
contact could be found at this time for the dates identified.
(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 6
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
01/09/2024
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)
F 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
The facility's policy titled Change in Condition Process issued on 3/02/19 read, The purpose of this policy is
to ensure the facility promptly informs the resident, consults the resident's physician; and notify . resident's
representative when there is a change requiring notification .Even when a resident is mentally competent,
his or her designated resident representative or family, as appropriate, should be notified of significant
changes in the resident's health status because the resident may not be able to notify them personally,
especially in the case of sudden illness or accident.
Event ID:
Facility ID:
105671
If continuation sheet
Page 2 of 6
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
01/09/2024
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)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, and record review, the facility failed to ensure a vulnerable, cognitively impaired resident had
adequate supervision for outside medical appointments, to prevent the potential for accidents, and
elopement for 1 of 3 residents reviewed for accidents of a total sample of 6 residents, (#1).
Findings:
Resident #1 was admitted to the facility on [DATE] with diagnoses of spinal stenosis lumbar region, lack of
coordination, intervertebral disc degeneration, dementia, Chronic Obstructive Pulmonary Disease, cognitive
communication disorder, Diabetes type II, repeated falls, and pain.
Review of the resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date
of 11/15/23 revealed the resident's cognition was severely impaired with a Brief Interview For Mental Status
(BIMS) score of 07 out of 15. The assessment revealed the resident required supervision or touching
assistance for toilet transfers, chair/bed-to-chair transfers, sit to stand, and walking. The assessment noted
the resident had two or more falls since his admission or prior assessment.
An Elopement Risk Evaluation dated 9/10/23 revealed the resident was at risk for elopement/wandering.
A care plan for elopement risk/wanderer revealed the resident attempted to leave the facility without
supervision. An intervention dated 9/10/23 read, must have direct supervision when outside the facility.
Review of the resident's care plan for falls risk initiated on 8/24/23 and revised 11/20/23, for risk for falls
read, be aware of resident's location and monitor for signs of fatigue which may increase fall risk.
Review of the appointment list for resident #1 provided by the facility revealed the resident went out to
medical appointments on 9/14/23, 9/26/23, 10/06/23, 10/11/23, 10/16/23, 11/22/23, 11/28/23, 12/06/23,
and 1/03/24.
Review of the Grievance log from October 2023 to current revealed an entry dated 1/02/24, which indicated
resident #1's wife verbalized that she wanted an escort to accompany the resident to his appointments.
Review of the resident's clinical records revealed a nursing progress note dated 9/26/23 that read, Resident
left to MD (Medical Doctor) appointment via wheelchair with CNA (Certified Nursing Assistant). A progress
note on 1/03/24, indicated the resident went to a physician's appointment accompanied by a CNA. No other
documentation could be identified to indicate the resident had supervision for the other seven medical
appointments.
On 1/05/24 at 3:33 PM, in a telephone interview, resident #1's wife stated the resident had dementia and
had fallen several times at the facility since his admission. She explained she worked and was unable to
accompany her husband to outside medical appointments. She recalled she spoke with the nurse at the
resident's Primary Care Physician's (PCP) office on 12/29/23 and was told the resident
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105671
If continuation sheet
Page 3 of 6
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
01/09/2024
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)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
was left alone at their office and was not picked up until approximately 6 PM. The PCP's nurse said she had
to wait with the resident and had to give him the paperwork from the visit. The resident's wife stated her
husband did not remember the visit, and she was not sure if he even took the paperwork. The resident's
wife said he will wander off if he has a chance to do it, and noted he had tried to get out of the facility. She
said he could have wandered out of the PCP's office, and she was not happy about it. She stated she
spoke to the Director of Nursing (DON) and wanted to know why her husband was dropped off at the PCP's
office and left alone.
On 1/08/24 at 11:17 AM, Licensed Practical Nurse (LPN) A, stated if a resident had dementia, and family
member could not accompany the resident to their medical appointment, the resident would be provided
with an escort from the facility. LPN A stated the need for an escort would be documented on the
appointment.
On 1/09/24 at 10:14 AM, Registered Nurse (RN) B stated resident #1 was very impulsive, hard of hearing,
and was at risk for falls. She explained that staff had to keep an eye on him, as he was impulsive and had
very poor safety awareness.
On 1/09/24 at 11:13 AM, the Director of Rehab stated resident #1 was currently on therapy caseload due to
falls. He indicated the resident was confused, had poor safety awareness and was impulsive at times.
On 1/09/24 at 1:05 PM, at 2:07 PM, and at 2:21 PM the Regional Director of Clinical Services (RDCS)
provided a list of resident #1's out of facility medical appointments. She stated she could not find notes to
indicate the resident was escorted to his appointments. The RDCS stated when residents went out for an
appointment, it was considered a Leave of Absence (LOA). She noted the resident should be signed out
and on return to the facility, signed in, and a progress note should be documented. Review of the resident's
clinical records revealed two progress notes dated 9/26/23, and 1/03/24 that indicated the resident had
supervision in the form of an escort for his appointments. Documentation could not be identified for the
other seven appointments the resident attended. The RDCS stated she reviewed the resident's clinical
records and could not identify documentation to correspond with the medical appointments. She stated she
had attempted to get a list from the transportation company regarding escort for the resident but could not
identify any additional documentation in the facility's records to indicate the resident had supervision for his
appointments.
On 1/09/24 at 3:28 PM, in a telephone interview, the previous Interim Administrator stated she was aware
resident #1's wife filed a grievance as the resident did not have a staff member with him when he went to
his medical appointments.
On 1/09/24 at 4:46 PM, the [NAME] President of Operation stated the appointments should have been
documented in the progress notes, and noted the facility needed improvement in documentation.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105671
If continuation sheet
Page 4 of 6
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
01/09/2024
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)
F 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, and record review, the facility failed to ensure medical records were complete and accurate for 1
of 2 residents reviewed for resident to resident abuse of a total sample of 6 residents, (#9).
Findings:
Resident #1 was admitted to the facility on [DATE] with diagnoses of spinal stenosis lumbar region, lack of
coordination, intervertebral disc degeneration, dementia, Chronic Obstructive Pulmonary Disease, cognitive
communication disorder, falls and persistent mood disorders.
Review of the resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date
(ARD) of 11/15/23 revealed the resident's cognition was severely impaired with a Brief Interview For Mental
Status (BIMS) score of 07 out of 15.
Resident #9 was admitted to the facility on [DATE]. His diagnoses included altered mental status, opioid
dependence, and alcohol abuse. Review of the resident's admission MDS assessment with ARD of
12/03/23 revealed the resident's cognition was intact with a BIMS score of 15 out of 15.
Review of the facility's incident and reportable logs from October 2023 to current showed an entry dated
1/06/24 of resident-to-resident altercation between resident #1 and resident #9.
The report revealed resident#1 held on to resident #9's wheelchair while resident #9 was in his wheelchair.
Resident #1 struck resident #9 twice on his arm and hit the Licensed Practical Nurse (LPN) who attempted
to separate the residents. The facility initiated an investigation into abuse, and the relevant state agencies
were notified.
Review of both residents' clinical record revealed documentation dated 1/06/23 for resident #1 of the
incident, however there was no documentation in resident #9's clinical record pertaining to the incident.
On 1/09/24 at 3:16 PM, resident #9 stated he had an incident with resident #1 a few days ago. He recalled
he was sitting in his wheelchair in the common area close to resident #1's room. He said resident #1
thought he was sitting in his wheelchair, and grabbed me. He said resident #1 was sitting in his own
wheelchair at the time of the incident. Resident #9 stated facility staff separated them, he went outside, and
had no further interaction with resident #1.
On 1/09/24 at 3:04 PM, Registered Nurse (RN) B recalled that on 1/06/24 resident #1, and resident #9
were sitting in their wheelchairs in front of resident #1's room door. Resident #1 held on to resident #9's
wheelchair, would not let it go, and at some point hit resident #9 twice on his arm. RN B recalled that when
she and another staff tried to separate the residents, resident #1 hit the other nurse. They separated them,
and resident #9 was taken outside, and resident #1 was placed on one-on-one supervision. RN B stated
resident #9, confirmed he was hit by resident#1, but he said he was okay, and was not in pain. She stated
she completed an incident report, and called resident #9's brother, and resident #1's wife. RN B stated she
completed a change in condition form for resident #1 but one was not completed for resident #9. RN B
explained she did not document the interaction in resident #9's clinical records, but completed an incident
report. She noted she should have documented the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105671
If continuation sheet
Page 5 of 6
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
01/09/2024
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)
F 0842
incident in the the resident's clinical record.
Level of Harm - Minimal harm
or potential for actual harm
On 1/09/24 at 3:44 PM, the Regional Director of Clinical Services (RDCS) stated that with
resident-to-resident abuse, documentation should be completed in the clinical records of both residents
involved. Review of the residents' clinical records revealed documentation regarding the incident was in
place for resident #1, but documentation regarding the incident could not be identified for resident #9. This
was confirmed by the RDCS.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105671
If continuation sheet
Page 6 of 6
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Back to topCitations
3 citations 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.
F580 - Notification of Changes
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
FAQ · About this visit
Common questions about this visit
What happened during the January 9, 2024 survey of AVANTE AT MELBOURNE INC?
This was a inspection survey of AVANTE AT MELBOURNE INC on January 9, 2024. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at AVANTE AT MELBOURNE INC on January 9, 2024?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) tha..."
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
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.