Inspection·August 4, 2022

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to ensure 2 of 3 residents discharged from Medicare Part A Skilled Services, Residents #340 and #52, were provided the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) (Form CMS-10055) to inform the resident of potential liability for payment and related standard claim appeal rights. Residents Affected - Some Findings include: Review of SNF Beneficiary Protection Notification Review form for Resident #52 reads, Medicare Part A Skilled Services Episode Start Date: 4/1/22. Last covered day of Part A Service: 5/20/22. Further review revealed no SNFABN, Form CMS-10055, was provided to the resident. Review of SNF beneficiary Protection Notification Review form for Resident #340 reads, Medicare Part A Skilled Services Episode Start Date: 5/14/22. Last covered day of Part A Service: 6/20/22. Further review revealed no SNFABN, Form CMS-10055, was provided to the resident. During an interview on 8/3/2022 at 1:27 PM, the Social Services Director verified that the SNFABNs, were not sent out to Residents #52 and #340. During an interview on 8/3/2022 at 1:27 PM, the Executive Director confirmed that the SNFABNs were not sent out to Residents #52 and #340. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105304 If continuation sheet Page 2 of 12 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 105304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at Leesburg, Inc 2000 Edgewood Ave Leesburg, FL 34748 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the residents received care for peripherally inserted central catheters in accordance with professional standards of practice for 1 resident with central venous access devices, Resident #4, in a total sample of 51 residents. Residents Affected - Few Findings include: During an observation on 8/1/2022 at 11:09 AM, Resident #4 was sitting up in a wheelchair with a right arm midline catheter with a transparent dressing with a 2 x 2 gauze under the dressing. The dressing was dated 7/31/2022. Review of Resident #4's record revealed the resident was admitted to the facility on [DATE] with the diagnoses including osteomyelitis of the left foot (an infection in the bone), non-pressure chronic ulcer of left heel and midfoot, type 2 diabetes mellitus, essential hypertension (high blood pressure), hyperlipidemia (high cholesterol), major depression, and anxiety disorder. Review of Resident #4's physician orders read, Order Summary: Meropenem Solution Reconstituted 500 mg [milligrams], use 500 mg intravenously every 6 hours for wound infection for 19 days. Order Date: 07/27/2022 . Order Summary: Normal Saline Flush Solution (Sodium Chloride Flush) use 10 milliliters intravenously every 12 hours for flush, flush 10 ml [milliliter] after IV [intravenous] medication. Order Date: 07/25/2022 . Order Summary: MID Line: Change Dressing to insertion site Right Upper Arm every 7 days and PRN [as needed] using sterile technique, one time a day every 7 day(s). Order Date: 07/21/2022 . Order Summary: MID Line: Change Dressing to insertion site Right Upper Arm every 7 days and PRN using sterile technique, as needed. Order Date: 07/21/2022. During an observation of intravenous (IV) medication administration by Staff B, Licensed Practical Nurse (LPN), for Resident #4 on 8/2/2022 at 11:51 AM, Staff B assembled all supplies and entered Resident #4's room. Staff B did not perform hand hygiene and donned gloves. Staff B removed an end cap from the right midline needleless connector, cleaned the needleless connector with alcohol for 2 seconds, connected a 10 ml (milliliter) syringe of 0.9% normal saline, and without checking for blood return, administered the normal saline. Staff B let go of the needleless connector, which rested on the resident's clothing. Staff B attached the IV line to the needleless connector without cleaning the connector. Staff B placed the IV line into the IV pump and received an air in line error message, removed the IV line from the IV pump and disconnected the IV line from the needleless connector. The needleless connector was resting on Resident #4's clothing. Staff B removed the air from the IV and connected the IV line to the needleless connector without cleaning the connector. The right arm midline catheter dressing was dated 7/31/2022 and had a 2 x 2 gauze under the transparent dressing. During an interview on 8/2/2022 at 12:10 PM, Staff B, LPN, stated, I should have cleaned the needleless connector for longer than I did. I did not check for blood return before I gave the normal saline and after I found air in the line. I should have cleaned the connector again. The dressing doesn't need to be changed. It was changed on 7/31 and it is good for a week even with gauze under it. During an observation of Resident #4 on 8/3/2022 at 11:31 AM, the right arm midline catheter dressing was dated 7/31/2022 with a 2 x 2 gauze under the transparent dressing. During an interview on 8/3/2022 at 12:00 PM, the Director of Nursing (DON) stated, All central line (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105304 If continuation sheet Page 3 of 12 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 105304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at Leesburg, Inc 2000 Edgewood Ave Leesburg, FL 34748 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dressings should have a transparent dressing on them. If there is gauze under the transparent dressing, it gets changed every 2 days. Review of the facility policy and procedures titled 5.1 Central Vascular Access Device (CVAD) Flushing and Locking last revised on 6/1/2021 and approved on 1/21/2022, reads: Considerations . 4. Flushing/locking is performed to ensure and maintain catheter patency and to prevent the mixing of incompatible medications/solutions. 5. Needleless connectors require vigorous cleansing with alcohol prior to accessing to reduce the risk of catheter related bloodstream infection . Guidance . 5. Catheter patency must be verified prior to each medication administration. To assess patency, aspirate the catheter to obtain positive blood return. The aspirated blood should be the color and consistency of whole blood . Procedure . 4. Perform hand hygiene. 5. Assemble equipment and supplies on clean work surface. 6. [NAME] gloves. 7. Vigorously cleanse needleless connector with alcohol. Allow to air dry . 9. Attach syringe filled with prescribed flushing agent to needleless connector. Aspirate the catheter to obtain positive blood return to verify vascular access patency. Review of the facility policy and procedures titled 5.2 Central Vascular Access Device (CVAD) Dressing Change last revised on 6/1/2021 and approved on 1/21/2022 reads, Considerations . 2. The catheter insertion site is a potential entry site for bacteria that may cause catheter-related infection. 3. A transparent dressing is the preferred dressing, if the patient is allergic to the transparent dressing, a sterile gauze and sterile tape dressing may be used . Guidance . 2. When a transparent dressing is applied over a sterile gauze dressing it is considered a gauze dressing and is changed: . 2.2 Every 2 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105304 If continuation sheet Page 4 of 12 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 105304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at Leesburg, Inc 2000 Edgewood Ave Leesburg, FL 34748 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During an observation on 8/1/2022 at 8:38 AM, Resident #20's oxygen delivery tubing was dated 7/17/2022. Residents Affected - Some During an observation on 8/2/2022 at 9:28 AM, Resident #20's oxygen delivery tubing was dated 7/17/2022. During an interview on 8/2/2022 at 1:18 PM, Staff A, License Practical Nurse (LPN), stated that respiratory tubing was changed on 11 PM-7 AM shift by nursing nightly. Staff A confirmed that Resident #20's oxygen tubing was dated 7/17/202 and was not changed as ordered. Review of the medical records for Resident #20 revealed the resident was admitted on [DATE] with the diagnoses including heart failure, atrial fibrillation, tobacco use, and shortness of breath. Review of the physician orders dated 7/8/2021 for Resident #20 revealed the order for changing the oxygen set up and bag weekly and as needed. Based on observation, interview, and record review, the facility failed to ensure the residents received respiratory care services consistent with professional standards of practice for 3 of 6 residents reviewed for oxygen administration and respiratory care, Residents #41, #59, and #20, in a total sample of 51 residents. Findings include: 1. During an observation on 8/1/2022 at 10:29 AM, Resident #41 was sitting in bed with an oxygen mask around his tracheostomy. The oxygen tubing was labeled with a date of 7/17/2022. There was an undated empty water humidification bottle. There was tubing for a passive nebulizer that was laying on the overbed table without a plastic bag and suction tubing with a flexible suction catheter connected to the tubing that was laying on nightstand with no plastic bag or packaging covering the tubing. There was a dried tannish brownish secretion in the suction catheter. The oxygen concentrator was set on 3 liters of oxygen. Review of the medical records for Resident #41 revealed the resident was admitted to the facility on [DATE] with the diagnoses including chronic obstructive pulmonary disease, tracheostomy (a surgical opening of the windpipe to help breathing), malignant neoplasm of laryngeal cartilage (cancer of the larynx), dysphagia, essential primary hypertension, and hyperlipidemia (high cholesterol). Review of the physician orders for Resident #41 reads, Order Summary: Oxygen continuous at 2 liters/ min via trach (tracheostomy). Medical DX [diagnosis]: laryngeal mass. Every shift . Order Status: Active. Order Date: 08/03/2022 . Order Summary: Oxygen continuous at 5 liters/ min via trach. Medical DX: trach. Every shift . Order Status: Discontinued. Order Date: 12/10/2021. Start Date: 12/10/2021. End Date: 08/02/2022. Review of the physician orders for Resident #41 reads, Order Summary: Ipratropium-Albuterol Solution 0.5-2.5 (3) MG [milligrams]/3 ML [milliliters] 1 dose via trach every 8 hours as needed for sob [shortness of breath] related to chronic obstructive pulmonary disease . Order Summary: Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3 ML 1 dose via trach every 8 hours for sob related to chronic obstructive pulmonary disease . Order Summary: Change oxygen set up and bag weekly and as needed every (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105304 If continuation sheet Page 5 of 12 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 105304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at Leesburg, Inc 2000 Edgewood Ave Leesburg, FL 34748 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some night shift every sat [Saturday]. Place in labeled O2 [oxygen] bag and tie to handle of O2 concentrator. Further review of the physician orders indicated there were no physician orders for tracheostomy care. During an observation on 8/1/2022 at 1:45 PM, Resident #41 was sitting in bed with a tracheostomy mask and tubing labeled 7/17/2022. There was an undated empty water humidification bottle. There was tubing for a passive nebulizer that was laying on the resident's overbed table. There was a suction cannister on the resident's nightstand with a flexible suction catheter that was not in packaging or plastic bag and without date laying on the nightstand. The oxygen concentrator was set on 3 liters. During an interview on 8/1/2022 at 1:50 PM, Resident #41 stated, I have been out of water in the bottle for yesterday and today. I suction my own trach. The nurses never ask about when I suction myself. The nurses haven't done any trach care. They haven't changed it. They only do it when I ask them to. I guess I ask every week to have it changed and cleaned. During an interview on 8/1/2022 at 1:50 PM, Staff C, Licensed Practical Nurse (LPN), stated, Oh, the humidification bottle is empty and should not be. His oxygen is at 3 liters, and it is ordered for 5 liters and his tubing should be labeled when it is changed. His mask for his nebulizer should be in a bag not on the table. I don't know when his trach care is done. I know he suctions himself, so I don't suction him. I have not done his trach care. During an observation on 8/2/2022 at 7:05 AM, Resident #41 was in bed with tracheostomy mask with unlabeled and undated tubing, and a suction cannister on the nightstand. There was a flexible suction catheter that had tannish brown secretions within the tubing laying on the nightstand, not in a plastic bag or the original packaging. There was a passive nebulizer tubing on the resident's overbed table that had plastic bag. Oxygen was running at 3 liters via concentrator. During an interview on 8/2/2022 at 12:30 PM, the Unit Manager, LPN, stated, There should be trach care orders. If we don't have any, then we can't prove we have given the care. We should follow doctor's orders and make sure if the resident has any concerns with the order that we call and let the doctor know and get new orders. The nurses should be making sure that the tubing is labeled and in a plastic bag and that after the resident uses suction tubing it gets thrown away. During an interview on 8/2/2022 at 12:55 PM, the Director of Nursing stated, [Resident #41's name] suctions his own trach, but we should be checking his tubing and throwing it out after each use. I am not sure why he doesn't have orders for trach care, he should. Nurses should check oxygen when they are giving their medications. We should not have respiratory equipment out of a plastic bag when it isn't being used. Review of the facility policy and procedures titled Quality of Care revised on 3/2/2019 and approved on 1/21/2022 reads, Policy: It is the policy of the facility to ensure that each resident receive and the facility provides the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care, in accordance with State and Federal Regulations. Definitions: Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and residents' choices. Procedure . 12. The facility will ensure that a resident, who (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105304 If continuation sheet Page 6 of 12 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 105304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at Leesburg, Inc 2000 Edgewood Ave Leesburg, FL 34748 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive resident-centered care plan, the residents goals and preferences.2. An observation on 8/1/2022 at 11:56 AM showed Resident #59's humidification bottle was dated 7/17/2022. The oxygen tubing was also dated 7/17/2022. During an interview on 8/1/2022 at 12:00 PM, Staff E, Licensed Practical Nurse (LPN), stated, [Resident #59's Name] does not like his tubing to be changed because he states the new tubing stinks. The humidification should have been changed. The humidification bottle should be changed every week. Review of the medical records for Resident #59 revealed the resident was most recently admitted on [DATE] with the diagnoses including chronic obstructive pulmonary disease (COPD), major depressive disorder, dry eye syndrome, hallucinations, and anxiety. Review of the physician orders dated 5/19/2022 for Resident #59 revealed the prescription for oxygen continuous at 2 liters via nasal cannula for COPD. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105304 If continuation sheet Page 7 of 12 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 105304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at Leesburg, Inc 2000 Edgewood Ave Leesburg, FL 34748 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety. Residents Affected - Many Findings include: During the initial tour of the facility's kitchen on 8/1/2022 at 7:15 AM, there was a clear plastic container with blue lid containing sugar, with a small plastic bowl lying on top of the sugar; and a clear plastic container with blue lid containing rice, with the lid not closed tightly and a small clear plastic bowl lying on top of the rice. During an interview on 8/1/2022 at 7:18 AM, the Food Services Director confirmed the food storage containers should be tightly closed at all times and should not have any utensils in them being used as scoops. Review of the facility policy titled Food Storage: Dry Goods dated 5/2014 and approved on 1/21/2022 reads, All dry goods will be appropriately stored in will be appropriately stored (SIC) in accordance with the FDA [Food and Drug Association] Food Code . Procedures . 5. All packaged and canned food items will be kept clean, dry, and properly sealed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105304 If continuation sheet Page 8 of 12 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 105304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at Leesburg, Inc 2000 Edgewood Ave Leesburg, FL 34748 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 observation, interview, and record review, the facility failed to maintain complete and accurately documented medical records for 1 of 3 residents reviewed for closed records, Resident #90, in a total sample of 51 residents. Findings include: Review of the medical records for Resident #90 revealed the resident was admitted to the facility on [DATE] with the diagnoses including malignant neoplasm of the prostate (prostate cancer), secondary malignant neoplasm of the bone (bone cancer), primary generalized osteoarthritis, type 2 diabetes mellitus, atherosclerotic heart disease of native coronary artery (heart disease), atrial fibrillation (an irregular heart beat), peripheral venous insufficiency, and primary (essential) hypertension (high blood pressure). Review of Resident #90's progress note dated 6/6/2022 authored by Advanced Practice Registered Nurse (APRN) reads, Assessments: 1. Atherosclerotic heart disease of native coronary artery without angina pectoris, 2. Paroxysmal Atrial fibrillation, 3. Retention of Urine, unspecified, and 4. Hypotension, unspecified. Treatment: 3. Retention of urine unspecified: Notes: Foley catheter placed given patient was complaining of distention and tenderness upon palpation of bladder. 550 cc [cubic centimeters] of dark concentrated urine noted in bag. U/A [urinalysis] and Urine cx [culture] sent. 4. Hypotension, unspecified: Notes: Patient with low b/p [blood pressure]. O2 [oxygen] placed as patient looked pale and was clammy. EMS [Emergency Medical Services] arrived and per their criteria patient meet the sepsis [a life-threatening complication of an infection] protocol criteria. Will follow up further workup from hospital. Review of the nursing progress notes for Resident #90 revealed no documentation of urinary catheter insertion. Review of Resident #90's vital signs records revealed no blood pressure documented on 6/6/2022. Review of Resident #90's physician orders revealed no physician order to transfer to hospital. During an interview on 8/2/2022 at 1:10 PM, the Director of Nursing stated, I do not see any physician orders or nursing progress notes to indicate why he went out to the hospital. There are no notes indicating he had a Foley catheter inserted and there are no blood pressures documented on the day he was transferred. There is a note from the APRN, which details what occurred. But we should have recorded vital signs and transfer notes. The transfer form does have the date of 12/17/2021 as the day of transfer, which is not correct. There should be documentation from the nurse, and I can't tell you why there isn't. Review of the facility policy and procedures titled Notice Requirements Before Transfer/Discharge revised on 3/2/2019 and approved on 1/21/2022 reads, Procedure: 1. Before the facility transfers or discharges a resident, the facility will: a. Obtain a physician's order for the transfer and or discharge . d. Record the reasons for the transfer or discharge in the resident's medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105304 If continuation sheet Page 9 of 12 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 105304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at Leesburg, Inc 2000 Edgewood Ave Leesburg, FL 34748 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to prevent the possible development and transmission of communicable diseases and infections. The facility failed to ensure staff performed hand hygiene during medication administration in 6 of 9 observations of medication administration and followed infection control standard of practice in 3 of 8 observations of urinary catheter care. Residents Affected - Some Findings include: 1. During an observation of medication administration on 8/2/2022 at 8:18 AM, Staff A, Licensed Practical Nurse (LPN), prepared medications for Resident #44, entered the resident's room and administered the medications without performing hand hygiene. Staff A exited the room and went to the central supply room to find additional medication for Resident #44. Staff A returned to the medication cart and performed hand hygiene. Staff A took a bottle of Vitamin D, removed a black permanent marker from her pocket and dated the bottle, opened the bottle, removed the protective lining on the opening, poured the medication, locked the medication cart, and returned to Resident #44's room. Staff A administered the additional medication, exited the room, returned to the medication cart, and began preparing medications for another resident. Staff A did not perform hand hygiene. During an observation of medication administration on 8/2/2022 at 8:28 AM, Staff A, LPN, prepared medications for Resident #28, entered the resident's room and administered the medications without performing hand hygiene. Staff A returned to the medication cart and began preparing medications for another resident. Staff A did not perform hand hygiene. During an observation of medication administration on 8/2/2022 at 8:35 AM, Staff A, LPN, prepared medications for Resident #1, entered the resident's room and administered the medications and exited the room. Staff A returned to the medication cart and began preparing medications for another resident. Staff A did not perform hand hygiene. During an interview on 8/2/2022 at 8:45 AM, Staff A, LPN, stated, I was nervous being watched, but I should have used hand sanitizer or washed my hands when I was giving the meds. During an observation of intravenous (IV) medication administration by Staff B, LPN, for Resident #4 on 8/2/2022 at 11:51 AM, Staff B assembled all supplies and entered the resident's room. Staff B did not perform hand hygiene and donned gloves. Staff B removed an end cap from the right midline needleless connector and cleaned the needleless connector with alcohol for 2 seconds. Staff B did not allow the needleless connector to air dry and administered 10 milliliters (ml) of 0.9% normal saline. Staff B connected the IV antibiotic to the IV tubing and connected the tubing to the needleless connector without cleaning the needleless connector and started the IV antibiotic. Staff B removed gloves and exited the room without performing hand hygiene. During an interview conducted on 8/2/2022 at 11:58 AM Staff B, LPN stated, I should have washed my hands before putting on my gloves, I should have cleaned the connector for longer and after I gave the saline, I should have cleaned it again before I hung the IV. During an observation of medication administration on 8/3/2022 at 8:33 AM, Staff G, Registered Nurse (RN), performed a blood glucose check on Resident #8. Staff G returned to the medication cart and prepared Resident #8's medications without performing hand hygiene. Staff G administered the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105304 If continuation sheet Page 10 of 12 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 105304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at Leesburg, Inc 2000 Edgewood Ave Leesburg, FL 34748 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 0880 medications and returned to the medication cart. Staff G did not perform hand hygiene. Level of Harm - Minimal harm or potential for actual harm During an observation of medication administration on 8/3/2022 at 8:45 AM, Staff G, RN, prepared medications for Resident #65, administered the medications and returned to the medication cart and began preparing medications for another resident without performing hand hygiene. Residents Affected - Some During an observation of medication administration on 8/3/2022 at 8:55 AM, Staff G, RN, prepared medications for Resident #61, administered the medications, and returned to the medication cart and began preparing medications for another resident without performing hand hygiene. During an interview on 8/3/2022 at 9:10 AM, Staff G, RN, stated, I should have washed my hands or used hand sanitizer when I was administering my meds. During an interview on 8/3/2022 at 2:10 PM, the Director of Nursing stated, I would expect staff to follow our infection control principles and wash their hands. When staff administer IV meds, they need to clean the connector for 15 to 20 seconds before connecting the IV. Review of the facility policy and procedures titled 6.0 General Dose Preparation and Medication Administration last revised on 1/1/2022 reads, Procedure . 2. Prior to preparing or administering medications, authorized and competent Facility staff should follow Facility's infection control policy (e.g., handwashing). Review of the facility policy and procedures titled Infection Control- Hand Hygiene revised on 3/2/2019 and approved on 1/21/2022 reads, Policy: It is the policy of the facility to perform hand hygiene in accordance with national standards from the Centers for Disease Control and Prevention and the World Health Organization. Procedure . 2. Alcohol-based hand rub may be used for all other hand hygiene opportunities (e.g. when soap and water is not indicated per #1 above). According to the World Health Organization, hand hygiene is to be performed . d. After caring for a resident including after removing gloves. Review of the facility policy and procedures titled 5.1 Central Vascular Access Device (CVAD) Flushing and Locking last revised on 6/1/2021 and approved on 1/21/2022, reads: Considerations . 5. Needleless connectors require vigorous cleansing with alcohol prior to accessing to reduce the risk of catheter related bloodstream infection . Procedure . 4. Perform hand hygiene. 5. Assemble equipment and supplies on clean work surface. 6. [NAME] gloves. 7. Vigorously cleanse needleless connector with alcohol. Allow to air dry. Review of the procedure titled Intravenous (IV) Medication Administration approved on 1/21/2022 reads, Considerations for IV Medication Administration . Scrub needleless connector for a minimum of 15 seconds prior to each use. 2. During an observation on 8/1/2022 at 10:03 AM, Resident #78's indwelling Foley catheter bag was lying on the floor. During an observation on 8/1/2022 at 10:09 AM, Resident #16's indwelling Foley catheter bag was lying on the floor on the right side of his bed near the door. During an interview on 8/1/2022 at 10:30 AM, Staff E, LPN, stated, The catheter bag should not be lying on the floor. The bag should be hanging on the side of the bed. I am not sure how the catheter (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105304 If continuation sheet Page 11 of 12 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 105304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at Leesburg, Inc 2000 Edgewood Ave Leesburg, FL 34748 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 0880 bag got on the floor. Level of Harm - Minimal harm or potential for actual harm During an observation on 8/2/2022 at 3:10 PM, Resident #48 was propelling herself in her wheelchair down the hallway near the administrative offices and her Foley catheter drainage bag was dragging behind her wheelchair on the floor. The Administrator observed the Foley catheter drainage bag dragging on the floor. Residents Affected - Some During an interview on 8/2/2022 at 3:14 PM, the Administrator stated, I see the Foley catheter drainage bag is dragging on the floor. The bag is not supposed to be dragging on the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105304 If continuation sheet Page 12 of 12