Below 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 Rehabilitation Center during CMS and state inspections, most recent first.
A resident with a sacral pressure ulcer and severe cognitive impairment received wound care during which an LVN failed to follow proper infection control practices. After removing a soiled dressing, the LVN changed gloves without performing hand hygiene, then used the same gloves to cleanse and dry the wound and to handle and apply clean collagen, calcium alginate, and foam dressings from the bedside table. Hand hygiene was performed only after the dressing change was completed. In interviews, the LVN acknowledged she should have sanitized her hands after glove changes and before handling clean supplies, and the DON confirmed facility policy requires hand hygiene and glove changes when moving from dirty to clean tasks.
A medication error rate above 5% was identified when an LVN failed to administer two ordered medications and improperly administered a third to a newly admitted resident with multiple diagnoses. The errors occurred due to unavailable medications following a late admission and lack of timely pharmacy delivery, with the DON and Administrator providing statements about the facility's medication ordering and delivery processes.
Surveyors found that food items in the kitchen's freezer and refrigerator were not consistently labeled with item descriptions or dates, and some items were exposed to air. Staff interviews revealed inconsistent labeling practices, despite facility policy requiring all food to be covered, labeled, and dated.
A resident with multiple medical conditions did not receive a quarterly MDS assessment within the required three-month timeframe. The DON and MDS coordinator confirmed the delay, with the last assessment documented several months prior and no timely reassessment completed, contrary to facility policy and federal requirements.
The facility's kitchen failed to maintain proper sanitizer levels, with quaternary sanitizer in sanitation buckets at 500 ppm and the dishwasher cycle at 200 ppm, exceeding recommended levels. Dietary staff confirmed the discrepancy, acknowledging potential risks to residents and staff. The facility's policy outlined acceptable ranges, which were not followed.
The facility failed to submit discharge MDS assessments for five residents with various medical conditions, despite their discharges being documented in the EMR. The former MDS Coordinator may have been behind on submissions, leading to the oversight. The facility's policy requires comprehensive assessments at discharge, which was not followed.
A LTC facility reported a medication error rate of 8.57%, exceeding the acceptable 5% threshold. Errors included incorrect application of a pain patch for a resident, improper administration of eye ointment for another, and a missed dose of Vitamin D for a third resident. These errors were linked to training issues and misinterpretation of medication orders.
The facility failed to maintain an effective infection prevention and control program, as evidenced by unsanitized blood pressure cuffs used on multiple residents and inadequate PPE use during G-tube care for a resident. Staff did not adhere to infection control protocols, posing a risk of cross-contamination and infection.
A resident was inaccurately documented as having a tracheostomy in their MDS assessment, despite no evidence or history of such a procedure. Interviews with staff and review of records confirmed the error, which was attributed to human error during the assessment process.
A resident with multiple serious health conditions was found unresponsive and without a pulse. Despite being assessed as full code, the staff did not initiate CPR or use the AED as required by the facility's policy. The DON confirmed that the AED was not used, and the staff failed to follow emergency procedures, placing the resident at risk for harm.
Improper Hand Hygiene and Glove Use During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain an infection prevention and control program during wound care for one resident. The resident was an older adult female with a history of a sacral pressure ulcer and adult failure to thrive, with severely impaired cognition (BIMS score of 02) and a need for maximum two-person physical assistance with activities of daily living. During an observed wound care procedure, an LVN prepared wound care supplies on the bedside table, then entered the resident’s room with an RN. Both staff washed their hands and donned gloves and gowns. The LVN uncovered the resident, removed the soiled dressing from the sacral area, and discarded it in a biohazard bag. After removing the soiled dressing, the LVN removed her gloves and put on clean gloves without performing hand hygiene. With the same pair of clean gloves, she reached to the bedside table, obtained normal saline and gauze, cleansed the wound bed, and then patted it dry. Still without changing gloves or performing hand hygiene, she retrieved and applied collagen powder, calcium alginate, and a foam dressing from the bedside table. Only after completing the dressing change did she remove her gloves and gown and wash her hands. In a subsequent interview, the LVN acknowledged she was supposed to sanitize her hands after each glove change and to change gloves after cleaning the wound and before handling clean dressings. The DON stated that staff were required to change gloves and perform hand hygiene when moving from dirty to clean tasks and that failure to do so, as well as failure to keep supplies from contamination, placed residents at risk of infection and cross contamination. The facility’s hand hygiene policy identified hand hygiene as the primary means to prevent the spread of infections.
Medication Error Rate Exceeds 5% Due to Missed and Improperly Administered Doses
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with three medication errors observed out of 31 opportunities, resulting in a 9% error rate. During a medication pass, an LVN administered MiraLAX oral powder to a newly admitted female resident without the required amount of fluid, and failed to administer both Advair HFA inhalation aerosol and Isosorbide Mononitrate ER oral tablets as ordered. The resident had been admitted the previous night with diagnoses including hypertension, constipation, blood clots, and generalized weakness. Physician orders required these medications to be given at specific times, but the MAR indicated that only the MiraLAX was documented as given, and not according to the prescribed method. The LVN reported that the medications were not available in the pharmacy-provided stock machine and had not arrived with the morning pharmacy delivery. The LVN stated she informed the resident, the DON, and intended to follow up with the physician and pharmacy. The DON confirmed that late admissions often resulted in delayed medication delivery from the pharmacy and that staff were expected to notify both the physician and DON if medications were unavailable. The Administrator was unaware of any issues with medication delivery for late admissions and believed the pharmacy could be contacted at any time. Facility policy required medications to be administered according to established schedules and physician orders.
Failure to Properly Label and Store Food Items in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, food items in the freezer, such as large pizzas, tater tots, and hash browns, were found sealed but lacked item description labels and distinguishing dates. Additionally, one bag of hash browns was found opened and exposed to air. In the walk-in refrigerator, hardboiled eggs were stored in a sealed bag without an item description label, and the date on the bag was indistinguishable. These observations were made during a review of the facility's only kitchen. Interviews with the Kitchen Supervisor and staff revealed inconsistent practices regarding labeling and dating food items. The Kitchen Supervisor stated that labels sometimes fall off and, in such cases, items are relabeled with the date of an identical item or the date the item was found unlabeled. Responsibilities for labeling were divided among staff, with the PM Kitchen Aide, AM Kitchen Aide, and cook each responsible for different storage areas. The facility's Food Storage Policy requires all food stored in the refrigerator or freezer to be covered, labeled, and dated, but this was not consistently followed as evidenced by the survey findings.
Failure to Complete Timely Quarterly Assessment
Penalty
Summary
The facility failed to complete a quarterly assessment for one resident at least once every three months, as required by federal and state guidelines. Record review showed that the resident's last quarterly assessment was completed on a specific date, with no subsequent reassessment documented within the required timeframe. The resident's medical history included cerebral palsy, generalized anxiety disorder, and major depressive disorder. The MDS tab in the electronic health record confirmed the absence of a timely reassessment. During interviews, the DON stated that the MDS nurse was responsible for completing assessments and was unaware of the exact due dates, but expected them to be completed on time. The MDS coordinator confirmed that the last assessment was completed on the previously mentioned date and believed the assessment was still valid because the RUG had not expired, and the resident was scheduled for reassessment in August. The facility's policy requires assessments to be conducted and submitted according to current federal and state timeframes, but this was not followed in this instance.
Improper Sanitizer Levels in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its kitchen, specifically in maintaining appropriate levels of sanitizing chemicals. Observations revealed that the quaternary sanitizer levels in three sanitation buckets were at 500 ppm, and the three-compartment sink registered at 400 ppm, both exceeding the recommended levels. Additionally, the chlorine level in the dishwasher sanitizer cycle was at 200 ppm, which was higher than the facility's policy recommendation. These discrepancies were identified during an observation where the dietary staff used test strips to check the sanitizer levels, indicating a lack of proper monitoring and adjustment of chemical concentrations. Interviews with the dietary staff and the HR/DM confirmed that the sanitizer levels were supposed to be at 200 ppm for the buckets and 100 ppm for the dishwasher. The dietary staff mentioned that the levels were checked by the Dietary Manager earlier in the month and were deemed acceptable at that time. However, the staff acknowledged that high chemical levels could pose a risk to residents and staff. The facility's policy and the MSDS sheet for the sanitizer product outlined the acceptable ranges for sanitizer levels, which were not adhered to during the observed period.
Failure to Submit Discharge MDS Assessments
Penalty
Summary
The facility failed to submit discharge Minimum Data Set (MDS) assessments for five residents who were reviewed for discharge MDS submission. These residents included individuals with various medical conditions such as myasthenia gravis, cerebral infarction, type 2 diabetes mellitus with ketoacidosis, a fracture of the neck of the femur, and acute osteomyelitis. Despite their discharges being documented in the facility's electronic medical records (EMR), the discharge MDS assessments were not submitted for any of these residents, although their admission MDS assessments were accepted. Interviews with the facility's staff revealed that the former MDS Coordinator, who was responsible for completing these assessments, may have been behind on submissions and possibly missed some before leaving the position. The current MDS Coordinator, who was not involved at the time of the missing submissions, confirmed that if the discharge MDS assessments had been completed, they would appear in the EMR. The facility's policy requires that a comprehensive assessment of every resident's needs be conducted at designated intervals, including at discharge, but this was not adhered to in these cases.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 8.57% due to three errors out of 35 opportunities. These errors involved three residents, each with specific medication administration issues. Resident #9 did not receive her external pain-relieving patch on the correct body part as ordered by the physician. Instead of applying the patch to the right lateral hip, the patch was placed on both knees, which was not in accordance with the physician's orders. This error was attributed to a misunderstanding during the training of a medication aide, who was instructed to follow the resident's preference rather than the physician's order. Resident #35 experienced a medication error when an antibiotic eye ointment was administered in both eyes instead of only the left eye as prescribed. This mistake was made by a newly trained medication aide who followed the medication administration record (MAR) rather than the physician's specific order. The resident reported blurred vision in both eyes following the incorrect administration, which was confirmed by the resident's family member who witnessed the event. Resident #46 did not receive his prescribed daily Vitamin D tablet due to a medication aide's inability to locate the medication. The aide administered other medications but failed to provide the Vitamin D tablet, which was later found to be available in the facility's stock. This oversight was due to a misunderstanding of the medication order and the available stock, leading to a missed dose for the resident.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during the survey. For Residents #20, #46, and #83, the facility did not ensure that the medical assistant (MA D) sanitized the blood pressure cuff between uses. MA D was observed taking blood pressure readings for these residents without sanitizing the cuff between each use, which could lead to cross-contamination and the spread of infections. MA D admitted to forgetting to sanitize the cuff and acknowledged the risk of cross-contamination. Additionally, the facility failed to implement proper infection control measures for Resident #78, who required enhanced barrier precautions due to a G-tube. During medication administration, staff did not adhere to the required personal protective equipment (PPE) protocols. RN I and CNA F entered Resident #78's room with inadequate PPE, and ADON A handled the G-tube without gloves or PPE. This lack of adherence to infection control protocols posed a risk of contamination and infection for Resident #78. Interviews with staff, including CNA F, RN I, and ADON A, revealed a lack of compliance with infection control procedures, despite recent in-service training on the subject. The facility's policies on hand hygiene and infection control were not followed, as evidenced by the failure to sanitize equipment and use appropriate PPE. The administrator confirmed the expectation for staff to follow infection control policies, highlighting the risk of spreading germs when these precautions are not observed.
Inaccurate MDS Assessment for Tracheostomy
Penalty
Summary
The facility failed to ensure an accurate assessment for a resident, specifically regarding the presence of a tracheostomy. The resident, a male with a history of lung cancer, heart disease, asthma, and chronic kidney disease, was inaccurately documented as having tracheostomy care in his Significant Change MDS Assessment. This error was identified during a survey when the resident himself expressed confusion about the tracheostomy, showing no physical evidence of one. Further review of the resident's records, including order summaries and care plans, confirmed the absence of any tracheostomy-related documentation. Interviews with facility staff, including an RN and the Administrator, revealed that the resident never had a tracheostomy, and the error was likely due to human error during the MDS assessment process. The MDS Coordinator, who was not responsible for the initial assessment, acknowledged the mistake and suggested it might have been a simple clerical error. The facility's policy requires all individuals completing any portion of the MDS to certify the accuracy of the information, which was not adhered to in this instance.
Failure to Provide CPR to Full Code Resident
Penalty
Summary
The facility failed to ensure basic life support, including CPR, was provided to a resident requiring such emergency care prior to the arrival of emergency medical personnel. The resident, who was assessed as full code, was found unresponsive and without a pulse. Despite the facility's policy requiring immediate initiation of CPR and use of an AED, the staff did not perform these life-saving measures. The resident was found on the floor with blood around him, and the staff called 911 but did not attempt CPR or use the AED, citing the resident's cold and stiff condition as the reason for inaction. The resident's medical records indicated he had multiple serious health conditions, including sepsis, glaucoma, encephalopathy, pneumonia, atherosclerotic heart disease, diabetes mellitus, chronic kidney disease, and cardiomyopathy. His care plan and physician's orders clearly stated that he was to receive full code CPR in the event of cardiac arrest. However, when the resident was found unresponsive, the staff failed to follow these directives. The DON confirmed that the AED was not used and that the staff did not initiate CPR, despite the resident's full code status. Interviews with the staff involved revealed a lack of adherence to the facility's emergency procedures. The LVN and RN on duty did not perform CPR or use the AED, and there was confusion about the resident's code status. The DON and other staff members acknowledged that CPR should have been initiated immediately, regardless of the resident's condition. The facility's failure to provide the required emergency care placed the resident at risk for harm, including death, by denying all life-saving measures as trained.
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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.
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Nursing homes near Irving
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Irving | 0.7 mi | ★★★★★ | 10 | 0 |
| Ashford Hall | 1.4 mi | ★★★★★ | 14 | 0 |
| The Villages On Macarthur | 2.5 mi | ★★★★★ | 1 | 0 |
| Northgate Plaza | 3 mi | ★★★★★ | 16 | 0 |
| Las Brisas Rehabilitation And Wellness Center | 4.5 mi | ★★★★★ | 4 | 0 |
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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.