Inspection·January 25, 2024

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the medication error rate was not 5 percent or greater. The medication error rate was 20 percent. Residents Affected - Some Findings include: During an observation on 1/23/2024 beginning at 8:21 AM, Staff C, License Practical Nurse (LPN), administered Resident #42's medication via gastrostomy tube (G-tube, GT). Staff C administered Cholecalciferol oral tablet 125 micrograms (mcg) and one multivitamin and mineral tablet. The following medications were not administered during 9:00 AM medication pass: Midodrine oral tablet 5 mg (milligram) (Blood pressure 97/57); Artificial Tears ophthalmic solution 1.4% polyvinyl alcohol; and Metamucil oral powder 28.3% (Psyllium) 1 scoop. Review of Resident #42's physician orders dated 9/20/2023 showed the order read, Artificial Tears Ophthalmic Solution 1.4% (Polyvinyl Alcohol) Instill 1 drop in both eyes two times a day for dry eyes . Cholecalciferol Oral Tablet (Cholecalciferol) Give 25 mcg via G-tube one time a day for supplement . Multivitamin & Mineral Oral Liquid (Multiple Vitamins w/ [with] Minerals) Give 10 ml (milliliter) via G-tube one time a day for supplement . Midodrine HCl [Hydrochloride] Oral Tablet 5 mg (Midodrine HCl) Give 1 tablet via G-tube three times a day for hypotension hold if SBG [Systolic Blood Pressure] greater than 110. Review of Resident #42's physician order dated 12/21/2023 showed the order read, Metamucil Oral Powder 28.3% (Psyllium) Give 1 scoop via G-tube one time a day for diarrhea. During an interview on 1/23/2024 at 8:30 AM, Staff C, LPN, stated, I forgot to give the eye drops, Midodrine, and Psyllium. During an observation of medication administration for Resident #81 on 1/24/2024 beginning at 8:17 AM, Staff F, Registered Nurse (RN), did not administer Bumex 1 mg during medication pass. Review of Resident #81's physician order dated 9/28/2023 showed the order read, Bumex Oral Tablet 1 mg (Bumetanide) Give 1 tablet by mouth two times a day for diuretic. Review of Resident #81's Medication Administration Record (MAR) for January 2024 showed Bumex was on hold from January 1, 2024 through January 24, 2024. Review of Resident #81's physician note dated 1/18/2024 showed the note read, Continue Bumetanide Tablet, 1 mg, 1 tablet, Orally, twice a day. During an interview on 1/24/2024 at 2:00 PM, Staff F, RN, stated, Bumex 1 mg was on hold because the patient always refused it. I don't know who placed the medication on hold. During an interview on 1/24/2024 at 2:17 PM, the Advanced Registered Nurse Practitioner (ARNP) stated, Omitting the Midodrine for [Resident #42's name] was not critical. The patient's blood pressure fluctuates all the time. I did not place [Resident #81's name] Bumex on hold. The nurses should continue to try to encourage her to take the medication and if she refuses just document that she refuses. She needs to continue the Bumex. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105304 If continuation sheet Page 2 of 7 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 01/25/2024 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview on 1/24/2024 at 2:30 PM, the Director of Nursing (DON) stated, All medications are to be administered as ordered. The medications were omitted in error. Review of the facility policy and procedures titled Infection Control- Medication Administration last reviewed on 12/29/2023, showed the policy read, Policy: It is the policy of the facility to ensure that appropriate infection prevention and control measures are taken to prevent the spread of infection in accordance with State and Federal Regulations, and national guidelines. Procedure . 4. Verify medication name and label compared to physician order or medication administration record (MAR), verify dosage, and verify route of administration (i.e. orally, intravenous, or subcutaneous) . 6. Document medication taken, or refused by resident, including time and resident response to medication. Event ID: Facility ID: 105304 If continuation sheet Page 3 of 7 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 01/25/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. 2. During an observation on 1/22/2024 at 9:28 AM, Resident #94 was holding a medication cup that contained 7 pills of various shapes and colors in her hand. There was no nurse in Resident #94's room. During an interview on 1/22/2024 at 9:28 AM, Resident #94 stated that the pills were her medications. During an observation on 1/23/2024 at 9:43 AM, there was one white pill on Resident #94's bedside table. During an interview on 1/23/2024 at 9:43 AM, Resident #94 stated the white pill was an Imodium because she had an issue with diarrhea. Review of Resident #94's medication administration record for January 2024 showed the resident received Loperamide HCL (Imodium) oral tablet 2 milligrams by mouth as needed for diarrhea on 1/12/2024. During an interview on 1/23/2024 at 9:46 AM, Staff D, LPN, who was administering morning medications stated, I didn't leave a cup of meds [medications] in there [Resident 94's room]. It [the medications] could have been from the night shift. Sometimes her husband brings in medication. The Imodium could have been from before or brought in. Review of Resident #94's medication administration record for January 2024 showed documentation medications had been administered to Resident #94 on the 1/21/2024 evening shift. Review of Resident #94's medical records did not document a physician order or an assessment for the self-administration of medications. During an interview on 1/24/2024 at 10:37 AM, the Director of Nursing stated that she could not find a physician order or assessment for self-administration of medications for Resident #94 in the resident's medical record. Review of the facility policy and procedures titled Storage and Expiration Dating of Medications, Biologicals last reviewed on 12/29/2023 read, Procedure . 3.3. Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. 5. Once any medication or biological package is opened, Facility should follow manufacturers/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened or opened . 5.3. If a multi-dose vial of an injectable medication has been opened or accessed (e.g., needle-punctured), the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial . 10. Facility should ensure that medications and biologicals are stored at their appropriate temperatures according to the United States Pharmacopoeia guidelines for temperature range . 15. Facility should ensure that medications and biologicals for expired or discharged or hospitalized residents are stored separately, away from use, until destroyed or returned to the provider. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105304 If continuation sheet Page 4 of 7 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 01/25/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals were stored and labeled in accordance with currently accepted professional principles in 3 of 4 medication carts and failed to ensure medications were secured in 1 resident room, Resident #94. Findings include: Residents Affected - Some 1. During an observation of Medication Cart 2 on the 200 Hall of Wing 2 on 1/22/2024 at 9:59 AM with Staff A, License Practical Nurse (LPN), and Staff B, LPN, there were two opened multidose vials of Sulfamethoxazole 800 mg (milligrams)/10 ml (milliliters) and Trimethoprim 160 mg/10 ml with no dates or resident names written on the vials. During an interview on 1/22/2024 at 10:02 AM, Staff B, LPN, stated that the multiple dose vials should not be on the cart and should be dated when opened. During an interview on 1/22/2024 at 10:02 AM, Staff A, LPN, stated that the vials should not be in the cart and if they are opened, they should have the date opened written on the vials. During an observation of Medication Cart 1 on 100 Hall of Wing 1 on 1/22/2024 at 10:30 AM, there were one Insulin Glargine -YFGN U 100 pen with an expiration date of 1/11/2024 for Resident #95, and one Insulin Aspart 100 unit/ml pen with an expiration date of 1/19/2024 for Resident #262. There was one unopened insulin pen for Resident #310 delivered from pharmacy on 1/21/2024. During an interview on 1/22/2024 at 10:30 AM, Staff C, LPN, stated, The insulin pens in Cart 1 were expired and should not be used after they are expired. When the insulin is delivered, we are supposed to put the insulin in the refrigerator until it is removed for use for a resident. We will date it when we remove it from the refrigerator and open it for the patient. During an observation of Medication Cart 2 on 100 Hall of Wing 1 on 1/22/2024 at 11:48 AM, Staff E, LPN, there was one insulin pen for Resident #44, opened on 12/11/2023 and expired on 1/9/2024. During an interview on 1/22/2024 at 11:48 AM, Staff E, LPN, stated When the insulin is removed from the refrigerator, we put the open date and expiration date on the bag and pen and the insulin is supposed to be thrown away when expired. During an interview on 1/23/2024 at 10:40 AM, the Director of Nursing stated, All carts are to be checked by nursing and expired medications are to be thrown away and replaced. Insulin is to be stored in the refrigerator until it is needed for patient use. Then, it is opened and dated at that time. Review of the guideline provided by the facility titled Drug Storage Guide last reviewed on 12/29/2023, showed it read, Medication Cart Check . Supplements are refrigerated or dated as per manufacturer instructions . Documents . Multi-dose vials to be used for more than one resident are kept in a centralized medication area and do not enter the immediate resident treatment area (e.g., resident room). If multi-dose vials enter the immediate resident treatment area they should be dedicated for single resident use only. Multi-dose vials which have been opened or accessed (e.g., needle-punctured) should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105304 If continuation sheet Page 5 of 7 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 01/25/2024 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, record review, and interview, the facility failed to ensure staff performed hand hygiene during medication administration to help prevent the possible spread of infection and communicable diseases. Residents Affected - Few Findings include: During an observation on 1/23/2024 at 8:21 AM, Staff C, License Practical Nurse (LPN), exited Resident #77's room and pushed the medication cart to Resident #42's room. Staff C entered the room and obtained vital signs from right arm for Resident #42. Staff C did not wear gloves or perform hand hygiene. Staff C returned to the medication cart, verified physician orders, and began retrieving medications and placing medications into a medication cup. Staff C did not have gas relief medication. Staff C left the medication cart at 8:25 AM, leaving the containers of multiple medications on top of the cart unattended. Staff C returned to the medication cart, did not perform hand hygiene and proceeded to pour liquid medications including Lactulose oral solution 10 grams/15 milliliters (ml), Sucralfate oral suspension 1 gram /10 ml and Potassium Chloride liquid 20 milliequivalent (meq)/15 ml (10%) 30 ml into separate medication cups. Staff C crushed oral medications including Cyanocobalamin oral tablet 500 micrograms (mcg), Cranberry tablet, and Cholecalciferol tablet together. Staff C returned to Resident #42's room, did not perform hand hygiene, and administered the medications via gastrostomy tube. During an interview on 1/23/2024 at 8:30 AM, Staff C, LPN, stated, I know I should complete hand hygiene before and after medication administration. I always crush all her medications and give them at one time. During an observation on 1/24/2024 beginning at 8:17 AM, Staff F, Registered Nurse (RN), popped medication tablet from bubble packet for Resident #81. The tablet landed on medication cart. Staff F picked up the tablet with bare hands and placed the tablet in the medication cup. Staff F administered the medication to Resident #81. During an interview on 1/24/2024 at 8:25 AM, Staff F, RN, stated that she should have thrown the contaminated tablet away and obtained a new tablet for administration to Resident #81. During an interview on 1/24/2024 at 2:08 PM, the Director of Nursing stated, Hand hygiene is to be completed before and after administration of medication and pills that are dropped should be thrown away and a new medication obtained. Review of the facility policy and procedure titled Enteral Feeding Medication Administration last reviewed on 12/29/2023, showed the policy read, Policy: It is the policy of the facility to provide appropriate medication administration to residents who receive their medications via an enteral feeding tube to ensure that residents attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance to State and Federal regulation. Procedure . 8. Universal precautions and clean technique will be utilized when stopping, starting, flushing, and giving medications through the feeding tube. Review of the facility policy and procedures titled Infection Control- Hand Hygiene last reviewed on 12/29/2023 showed the policy read, 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 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105304 If continuation sheet Page 6 of 7 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 01/25/2024 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 Level of Harm - Minimal harm or potential for actual harm World Health Organization. Procedure . 2 . According to the World health Organization, hand hygiene is to be performed: a. Prior to caring for a resident . d. After caring for a resident including after removing gloves; e. After contact with the resident environment. 3. The Centers for Medicare and Medicaid State Operations Manual indicates that hand hygiene should be performed . i. Upon and after coming in contact with a resident's intact skin (e.g. when taking a pulse or blood pressure, and lifting a resident). Residents Affected - Few Review of the facility policy and procedures titled Infection Control- Medication Administration last reviewed on 12/29/2023 showed the policy read, Policy: It is the policy of the facility to ensure that appropriate infection prevention and control measures are taken to prevent the spread of infection in accordance with State and Federal Regulations, and national guidelines. Procedure: 1. Hand hygiene is performed prior to handling any medication . 10. If the sterility of a medication is compromised, or suspected of being compromised, the medication is discarded. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105304 If continuation sheet Page 7 of 7