Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avante At Inverness Inc during CMS and state inspections, most recent first.
Physicians and prescribers did not document patient-specific rationales when declining pharmacist recommendations for two residents, and nursing staff did not respond promptly to a pharmacist's recommendation for another resident. These actions resulted in incomplete documentation and delayed implementation of medication-related recommendations, contrary to facility policy.
A resident admitted with dementia, major depressive disorder, and anxiety disorder had physician orders and psychiatric notes supporting these diagnoses, as well as orders for anxiety medication. However, the MDS assessment failed to include anxiety disorder under active diagnoses, with staff interviews confirming the omission was due to the diagnosis being linked to dementia and not transferring into the MDS.
A resident admitted with multiple complex conditions, including a Foley catheter, did not have a baseline care plan developed for catheter care within 48 hours of admission. Incomplete documentation and lack of physician orders led to the omission, as the admission assessment did not accurately reflect the presence of the catheter, resulting in the care plan not addressing this critical need.
The facility did not ensure that comprehensive care plans were developed and implemented for two residents. One resident with anxiety and dementia did not have an anxiety management plan in place despite an active medication order, and another resident at risk for falls did not have required floor mats in place as specified in the care plan. Staff interviews confirmed these omissions and lapses in following care plan interventions.
Three residents with hypertension and complex medical histories received antihypertensive medications despite physician orders specifying hold parameters for low systolic blood pressure. Nursing staff administered Metoprolol and Nifedipine outside of these parameters and did not notify providers as required. Staff interviews revealed awareness of the parameters but failure to follow them, as well as confusion about the medication administration system.
Several residents received oxygen at flow rates higher than prescribed, and staff were not consistently aware of or following physician orders for respiratory care. Additionally, a nebulizer mask was repeatedly left unbagged and not stored according to facility policy, contrary to infection control guidelines. These deficiencies were confirmed through observations and staff interviews.
A resident with multiple wounds did not have wound care accurately documented on several dates, despite physician orders specifying required treatments. Review of the Treatment Administration Record showed missing entries for wound care, and staff interviews confirmed that documentation was not completed and refusals were not recorded. The wound care nurse and DON acknowledged inconsistencies in documentation and communication among nursing staff.
Failure to Document Rationale for Declining Pharmacist Recommendations and Delayed Nursing Response
Penalty
Summary
The facility failed to ensure that physicians or prescribers documented the rationale for declining pharmacist recommendations for two residents reviewed for unnecessary medications. In both cases, the consultant pharmacist made specific recommendations regarding medication adjustments or monitoring, such as attempting a gradual dose reduction of psychotropic medications and initiating additional pain management or laboratory monitoring. The prescribers declined these recommendations but did not provide any patient-specific rationale or explanation in the medical record, as required by facility policy and procedure. Interviews with the Director of Nursing and the Advanced Practice Registered Nurse confirmed that explanations were not consistently provided, and the expectation for documentation was not always met. Additionally, the facility did not ensure timely nursing response to a pharmacist's recommendation for another resident. The pharmacist recommended updating an inhaled corticosteroid order to include instructions for rinsing the mouth after use to reduce the risk of thrush. The recommendation was not addressed promptly, and the order remained unchanged without the additional instructions. The Director of Nursing acknowledged that recommendations are typically addressed within 48-72 hours but could not explain the delay in this instance. Review of facility policy confirmed that prescribers are expected to document their rationale for rejecting pharmacist recommendations and that the nursing department should act upon such recommendations in a timely manner. The records reviewed showed that these procedures were not consistently followed, resulting in incomplete documentation and delayed implementation of pharmacist recommendations.
Inaccurate Resident Assessment for Medication Management
Penalty
Summary
The facility failed to ensure the accuracy of resident assessments for one resident reviewed for medication management. The resident was admitted with diagnoses including dementia, major depressive disorder, and an anxiety disorder, as documented in the admission record and physician orders. Despite these diagnoses and corresponding physician orders for psychiatric evaluation and medication for anxiety, the Minimum Data Set (MDS) assessment did not include anxiety disorder under Section I-Active Diagnoses. The MDS Coordinator confirmed that the medication section indicated anxiety and depression, but the anxiety diagnosis was not included in the MDS because it was attached to the dementia diagnosis and did not transfer over. The Director of Nursing stated that the facility follows the RAI manual.
Failure to Develop Baseline Care Plan for Catheter Care Upon Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a newly admitted resident. The resident was admitted with multiple complex diagnoses, including malignant neoplasm of the uterus, acute respiratory failure, a left femur fracture, a pressure ulcer, constipation, dependence on supplemental oxygen, generalized anxiety disorder, lymphedema, malignant melanoma, and obstructive and reflux uropathy. Documentation showed the resident was incontinent of bladder and had a Foley catheter inserted prior to admission. However, the admission evaluation did not accurately reflect the presence of the Foley catheter or obstructive uropathy, as these were either unchecked or not marked on the assessment form. As a result, the baseline care plan created at admission did not include any focus, goal, or intervention related to urinary catheter care. Interviews with staff revealed that the absence of documentation regarding the catheter in the admission assessment and lack of physician orders led to the omission of catheter care in the baseline care plan. The facility's policy requires a baseline care plan to be developed within 48 hours of admission, but this was not followed in this case due to incomplete or inaccurate documentation and assessment.
Failure to Develop and Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents as required. For one resident with diagnoses including anxiety disorder, depression, and unspecified dementia, the care plan did not include any focus, goal, or intervention related to anxiety management, despite an active physician order for Buspirone to treat anxiety. The MDS Coordinator acknowledged that the anxiety focus had been marked as resolved months earlier and recognized the omission, noting that daily order reviews occur but the care plan update was overdue. For another resident with multiple diagnoses including convulsions, osteoporosis, spastic hemiplegia, contractures, traumatic brain injury, and epilepsy, the care plan identified a risk for falls and specified the use of floor mats at the bedside as an intervention. However, during multiple observations, the floor mats were not in place as required, instead being found propped against furniture. Staff interviews confirmed that the mats should have been in place and that staff are expected to review and follow the care plan each shift, but the intervention was not implemented as documented.
Failure to Follow Physician-Ordered Parameters for Hypertension Medications
Penalty
Summary
The facility failed to ensure that physician-ordered parameters for administering hypertension medications were followed for three residents reviewed for medication management. For one resident with diagnoses including congestive heart failure, ischemic cardiomyopathy, COPD, and pneumonia, Metoprolol Tartrate was ordered to be held if systolic blood pressure (SBP) was less than 110 or heart rate less than 60. Despite this, the medication was administered multiple times when the resident's SBP was below the specified threshold, as documented in the Medication Administration Record (MAR) for June and July. Staff interviews confirmed that the medication was given outside of the ordered parameters and that the physician was not notified as required. Another resident with a history of cerebral infarction, myocardial infarction, bacteremia, and endocarditis had orders for Nifedipine and Metoprolol Tartrate to be held for SBP less than 120. The MAR showed that both medications were administered on several occasions when the resident's SBP was below the ordered parameter. Staff interviews revealed that the nurses were aware of the parameters but did not withhold the medication or contact the physician, and there was no documentation of physician notification. A third resident with muscle weakness, anxiety disorder, depression, dementia, and hypertension had an order for Metoprolol Succinate to be held for SBP less than 120. The MAR indicated that the medication was administered when the resident's SBP was below the specified parameter. Staff interviews indicated confusion about the medication administration system and the meaning of checkmarks, as well as uncertainty about whether the correct procedures were followed. The DON confirmed that the system does not auto-populate blood pressures and that staff are responsible for entering and following the parameters as ordered.
Failure to Follow Physician Orders and Infection Control Practices in Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care as ordered by physicians for four residents reviewed. Multiple residents were observed receiving oxygen at flow rates higher than those prescribed in their physician orders. For example, one resident was receiving oxygen at 4 liters per minute via nasal cannula, despite an order for 2 liters per minute as needed for shortness of breath. Another resident with a tracheostomy and a speaking valve was also observed with oxygen set at 4 liters per minute, contrary to the physician's order for 2 liters per minute. Staff interviews confirmed that the oxygen flow rates being administered did not match the physician orders, and staff were not always aware of the correct prescribed rates. Additionally, a third resident was observed receiving oxygen at 4 liters per minute when the order specified 3 liters per minute as needed, with physician notes indicating a range of 2-3 liters to maintain oxygen saturation above 92%. In another instance, a resident's nebulizer mask was repeatedly found unbagged and left on top of a drawer when not in use, despite physician orders and facility policy requiring the mask to be bagged and changed weekly or as needed. Staff interviews confirmed that the nebulizer mask should have been bagged when not in use, and the DON acknowledged this expectation. Review of facility policy indicated that oxygen and respiratory equipment should be managed according to professional standards and infection control guidelines, including keeping delivery devices covered when not in use. These observations and interviews demonstrate that the facility did not consistently follow physician orders or its own policies regarding respiratory care and equipment management.
Failure to Accurately Document Wound Care for a Resident
Penalty
Summary
The facility failed to ensure accurate documentation of wound care for a resident with multiple wounds, as required by physician orders and professional standards. Review of the Treatment Administration Records (TAR) for the resident revealed multiple dates across June and July where wound care treatments for various sites—including the right and left ischial areas, right heel, right posterior thigh, left posterior thigh, and coccyx—were not documented. Physician orders specified detailed wound care regimens for each site, but there were no entries on several specified dates, indicating either the care was not provided or not recorded. Interviews with staff confirmed that documentation was missing and that refusals by the resident were not recorded, despite the resident stating they did not refuse care. Further interviews with the Assistant Director of Nursing (ADON), Director of Nursing (DON), and the wound care nurse revealed inconsistencies in the process for reporting and documenting wound care, especially when performed by night shift nurses. The wound care nurse acknowledged gaps in the TAR and a lack of consistent communication or reporting from night shift staff regarding missed wound care. The DON confirmed the expectation that wound care should always be documented, and the ADON noted that refusals should have been documented if they occurred. The absence of documentation on the TAR for the specified dates led to the deficiency finding.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 107 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Inverness
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Citrus Health And Rehabilitation Center | 0.3 mi | ★★★★★ | 0 | 0 |
| Arbor Trail Rehab And Skilled Nursing Center | 1.1 mi | ★★★★★ | 0 | 0 |
| Grove Healthcare And Rehabilitation Center And Reh | 7.9 mi | ★★★★★ | 0 | 0 |
| Aviata At Brentwood | 9.4 mi | ★★★★★ | 6 | 0 |
| Life Care Center Of Citrus County | 9.8 mi | ★★★★★ | 10 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Avante At Inverness Inc.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.