Inspection·April 17, 2025

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Medicaid Services. The assessment system will provide a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacities and assist staff to identify health problems for care plan development. 2) Review of the admission record for Resident #17 documented the resident was admitted to the facility on [DATE] with diagnosis that included chronic kidney disease and type 2 diabetes mellitus. Review of Minimum Data Set (MDS) admission assessment, dated 4/6/2025, documented that Resident #14 was receiving dialysis services while a resident at the facility. Review of physician orders for Resident #14 documented no orders for dialysis. During an interview on 4/14/2025 at 9:24 AM, Resident #14 stated, I am not on dialysis. During an interview on 4/17/2025 at 1:15 PM, the Travel MDS Coordinator stated, We review the physician orders, hospital discharge documents, assessments and progress notes when completing the MDS. I was not here at this time. During an interview on 4/17/2025 at 2:20 PM, the Director of Nursing (DON), stated, It is expected that the MDS is updated immediately upon change of situation/condition. That reflects any and all changes regarding residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105304 If continuation sheet Page 2 of 18 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 04/17/2025 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure Preadmission Screening and Resident Review (PASRR) was accurately completed for 3 (Resident #55, #66, #70, ) of 7 residents reviewed for mood and behavior Residents Affected - Few Findings include: 1)Review of Resident #70 Stated of Florida Agency for Health Care Administration Preadmission Screening and Resident Review (PASRR) dated 3/8/2024 did not document depressive disorder. Review of Resident #70 admission record resident was admitted on [DATE] with diagnosis included but not limited to anxiety disorder, depression, low back pain, and auditory hallucinations. Review of Resident #70 physician order dated 12/12/2024 Sertraline HCI Oral Tablet 50mg (milligrams) give 50mg by mouth one time a day for depression. During an interview on 4/16/2025 at 5:15 PM with [NAME] President of Clinical Operations stated , [Resident #70's name] depressive disorder should have be included in the level one before admission to the facility. Social Services reviews the PASRR and checks for accuracy and if they need to correct anything they will tell a nurse to correct it. During an interview on 4/16/2025 at 5:43 PM with the Director of Nursing stated, [Resident #70 name] PASRR was missed it should have been updated when she [Resident #70] came in from the hospital, but it was missed. Review of the facility policy and procedure titled Coordination-Pre-admission Screening and Resident Review (PASRR) Program with a last review date 2/19/2025 read, Policy: It is the policy of the facility to assure that all residents admitted to the facility received a Pre-admission Screening and Resident Review in accordance with State and Federal Regulation. 2.) Review of Preadmission Screening and Resident Review (PASRR) dated 10/19/2022 read that Resident #55 did not have or was not suspected of having any mental illness. Review of physician order dated 9/18/2024 for Resident #55 read, Fluoxetine HCL Oral Capsule 20 mg (milligram), give 40 mg by mouth one time a day related to Major Depressive Disorder, Recurrent, Moderate. Review of physician order dated 1/24/2025 for Resident #55 read, Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 mg, give 2 capsules by mouth every 8 hours related to unspecified Dementia, unspecified severity, with other behavioral disturbances. Review of physician order dated 3/25/2025 for Resident #55 read, Trazodone HCL Oral Tablet 100 mg, give 0.5 tablet by mouth one time a day for depression related to Major Depressive Disorder, single episode, moderate. Review of psychiatry subsequent note dated 3/25/2025 for Resident #55 read, This is a [AGE] year-old patient with a past psychiatric history of depression, anxiety, dementia, insomnia and bipolar disorder .Today, I saw the patient as it was reported to me that the patient is unstable requiring (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105304 If continuation sheet Page 3 of 18 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 04/17/2025 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 0645 psychiatric assessment. Level of Harm - Minimal harm or potential for actual harm Review of psychiatry subsequent note dated 4/1/2025 for Resident #55 read, Today, I saw the patient to assess tolerability and effectiveness after recent medication changes .As per the collected information and interview, it appears that the patient is doing well overall. Residents Affected - Few During an interview on 4/17/2025 at 11:30 AM with the DON, she stated, The PASRR is incorrect, and a new one should have been completed. 3.) Review of Preadmission Screening and Resident Review (PASRR) dated 10/25/2023 read that Resident #66 did not have or was not suspected of having any mental illness. Review of physician order dated 2/21/2024 for Resident#66 read, Escitalopram Oxalate Oral Tablet 10 mg (milligram), give 1 tablet by mouth one time a day for depression related to major depressive disorder, single episode, mild. Review of physician order dated 7/2/2024, Depakote Sprinkles Capsule Sprinkle 125mg, give 2 capsules by mouth two time a day for mood disorder. Review of psychiatry subsequent note dated 3/25/2025 for Resident #66 read, This is a [AGE] year-old patient with a past psychiatric history of depression, anxiety, dementia, mood disorder .Today, I saw the patient to initiate gradual dose reduction (GDR). Review of psychiatry subsequent note dated 4/1/2025 for Resident #66 read, Today, I saw the patient to assess tolerability and effectiveness after recent medication changes .As per the collected information and interview, it appears that the patient is doing well overall. During an interview on 4/17/2025 at 11:30 AM with the DON, she stated, The PASRR is incorrect, and a new one should have been completed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105304 If continuation sheet Page 4 of 18 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 04/17/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observation, interviews and record review, the facility failed to develop and implement a comprehensive care plan for 1 (Resident #70) of 6 resident reviewed for medication management and 1 (Resident #42) of 6 residents reviewed for Hospice. Findings include: Review of Resident #70's physician order dated 12/12/2024, read, Sertraline HCI Oral Tablet 50mg (milligrams) give 50mg by mouth one time a day for depression. Review of Resident #70's Psychiatry Subsequent Note dated 4/8/2025 read, Chief complaint: Depression, anxiety, mood disorder and schizophrenia . Review of Resident #70's comprehensive resident centered care plan did not document a focus for depression. During an interview on 4/17/2025 at 10:50 AM, the Regional MDS (Minimum Data Set) Specialist stated, [Resident #70' s Name] antidepressant focus was resolved and had to be included again in the resident's care plan. Review of the policy and procedure titled Comprehensive Care Plans with a last review date of 2/19/2025 read, Policy: It is the policy of the facility to promote seamless interdisciplinary care for our residents by utilizing the interdisciplinary plan of care based on assessment, planning, treatment, service and intervention. It is utilized to plan for and manage resident care as evidence by documentation from admission through discharge for each resident .The care plan will identify priority problems and needs to be addressed by the interdisciplinary team, and will reflect the residents strengths, limitations and goals. The care plan will be complete, current, realistic, time specific and appropriate to the individual needs for each resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105304 If continuation sheet Page 5 of 18 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 04/17/2025 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 Based on observations, interviews, and record reviews, the facility failed to ensure care and treatment was provided in accordance with professional standards of practice for 2 (Resident #84, #395) of 8 residents reviewed for central venous access devices and skin conditions. Residents Affected - Few Findings include: 1) During an observation on 4/14/2025 at 9:39 AM, Resident #84 was lying in bed, there was a dressing on Resident #84 left upper and forearm dated 4/10/2025. There was a pink gentle border dressing on Resident #84 upper right arm with no date or initials. (photographic evidence obtained) During an interview on 4/14/2025 at 9:39 AM, Resident #84 stated, I had a fall, and I got a few skin tears. During an observation on 4/16/2025 at 8:21 AM, Resident #84 was sitting up in bed eating breakfast. Resident #84's left upper and forearm had a dressing dated 4/10/2024. There was a pink gentle border dressing on Resident #84's upper right arm with no date or initials. Review of Resident #84's physician orders resident did not have wound care orders for skin tear prior to 4/11/2025. Review of Resident #84's physician order dated 4/11/2025 read, Clean skin tears with NS (normal saline), xeroform, gauze bandage. Review of Resident #84's physician order dated 4/14/2025 read, Clean skin tears with wound cleanser, pat dry, apply xeroform to skin tear, wrap with rolled gauze 3 x week (3 times a week) and prn (as needed) every day shift every Tue, Thu, Sat (Tuesday, Thursday, Saturday) for skin tear. Review of Resident #84's Weekly Skin Observation dated 3/25/2025 read, Skin conditions: 16) left antecubital skin tear, 17) right elbow skin tear, 37) Right knee (front) skin tear, and 38) left knee (front). Review of Resident #84 Weekly Skin Observation dated 4/4/2025 read, Skin conditions: 16) left antecubital skin tear, 17) right elbow skin tear, 37) Right knee (front) skin tear, and 38) left knee (front) skin tear. Review of Resident #84 Weekly Skin Observation dated 4/10/2025 read, Skin conditions: 16) left antecubital skin tear, 17) right elbow skin tear, 37) Right knee (front) skin tear, and 38) left knee (front) skin tear. During an interview on 4/16/2025 at 11:13 AM with Staff B, Wound Care, License Practical Nurse (LPN), stated, I was the one who put those dressing in place [left upper and forearm dressing] on 4/10/2024. [Resident #84's Name] wound care is done three times a week. Maybe the nurse did not know he would not be seen by the wound care doctor since they are skin tears. I am not sure why he has a dressing on his upper right arm. During an interview on 4/16/2025 at 11:57 AM, the Director of Nursing stated, Nursing staff should perform wound care as per doctor's orders and document appropriately and accurately the services (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105304 If continuation sheet Page 6 of 18 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 04/17/2025 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 provided to the residents. Level of Harm - Minimal harm or potential for actual harm Review of the policy and procedure titled Wound Management, with a last review date of 2/19/2025, read, Policy: The purpose of this program is to assist the facility in the care, services, and documentation related to the occurrence, treatment and prevention of pressure as well as, non-pressure related wounds. Procedure: 1 .The admitting nurse/nurse identifying a skin integrity issue, will then be responsible for initiating the appropriate intervention such as ensuring treatment order(s) are in place . Residents Affected - Few 2) During an observation on 4/14/2025 at 9:40 AM, Resident #395 was lying in bed; there was a single lumen picc (peripherally inserted central catheter) line on resident's right arm with a transparent dressing dated 4/1/2025. (photographic evidence obtained) Review of Resident #395's physician order dated 3/31/2025, read, PICC/MID line: Change dressing to insertion site (insert site) every 7 days and prn (as needed) using sterile technique. as needed. Review of Resident #395's physician order dated 3/31/2025, read, PICC/MID Line: RIGHT ARM) Dressing change 24 hours after insertion one time only for 24 hours after insertion for 1 day change dressing. During an interview on 4/16/2025 at 12:31 PM, the Director of Nursing stated, Intravenous dressing changes should be done weekly and as needed. Review of the policy and procedure titled PICC/Midline/CVAD (central venous access device) Dressing Change, with a last review date of 2/19/2025, read, Policy: It is the policy of this facility to change peripherally inserted central catheter (PICC), midline or central venous access device (CVAD) dressing weekly or if soiled, in a manner to decrease potential for infection and/or cross-contamination. Physician's orders will specify type pf dressing and frequency of changes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105304 If continuation sheet Page 7 of 18 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 04/17/2025 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 Based on observations, interviews, and record reviews, the facility failed to ensure respiratory care and services were provided in accordance with professional standards of practice for 3 (Resident #195, #82, and #36) of 6 residents reviewed for oxygen therapy and respiratory treatments. Residents Affected - Some Findings include: 1) During an observation on 4/14/25 at 10:17 AM, Resident 195's oxygen (O2) setting was on 4.5 liter (ltr), the O2 tubing is dated 4/6/25. (photographic evidence obtained) During an observation on 4/15/25 at 9:02 AM, Resident 195's oxygen (O2) setting was on 4.5 ltr, the O2 tubing is dated 4/6/25. During an observation on 4/15/25 at 3:36 PM, Resident 195's oxygen (O2) setting was on 4.5 ltr, the O2 tubing is dated 4/6/25. During an observation on 4/16/25 at 9:05 AM, Resident 195's oxygen (O2) setting was on 4.5 ltr, the O2 tubing is dated 4/6/25. Review of Resident 195's admission record documented an original admission date of 1/5/2025 and a readmission date of 3/1/2025 with diagnosis that included COPD (Chronic Obstructive Pulmonary Disease), asthma and severe protein malnutrition. Review of Resident 195's physician's order dated 3/8/25, reads, change oxygen set up and bag weekly and as needed. every night shift on Saturday. Review of Resident 195's physician's order dated 3/3/25, reads, Oxygen at 3 liters/min (minute) via nasal canula for SOB (shortness of breath). 2) During an observation on 4/14/25 at 1:35 PM, Resident #82's oxygen (O2) tubing date appears to be written over and with multiple numbers overlapping. It is unclear as to what the date actually is. During an interview on 4/14/25 at 1:35 PM, Resident #82 stated, I watch the staff change the date on oxygen tubing without actually changing the tubing. You can see they tried to put another date on top of the previous date, if you look at my roommate she did the same thing to his. I don't know her name, it was at night, they shouldn't do that. That is wrong. (Photographic evidence obtained) During an observation on 4/15/25 at 3:15 PM, Resident #82's O2 tubing was marked with multiple numbers overlapping, same as yesterday (4/14/25). During an interview on 4/15/25 at 3:15 PM, Resident #82 stated, it is still the same, no one has changed it. During an interview on 4/16/25 at 9:15 AM, Staff A, Licensed Practical Nurse (LPN), stated, The oxygen tubing should be changed weekly. I see the date; that should not be. During an interview on 4/16/25 at 9:15 AM, Resident #82 stated, I watch the staff change the date, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105304 If continuation sheet Page 8 of 18 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 04/17/2025 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 the nurse did it right in front of me. Level of Harm - Minimal harm or potential for actual harm During an interview on 4/16/25 at 10:00 AM, the Director of Nursing (DON) stated, that is unacceptable [changing date and not tubing], it is nursing 101; it is nursing standards of practice. Residents Affected - Some Review of the policy and procedure titled, Tracheostomy Care and Suctioning/Oxygen, last reviewed on 2/19/25, reads, Policy: The facility will ensure that residents who need respiratory care, including tracheostomy care and tracheal suctioning, is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan and resident goal and preferences. Procedures. 2. The facility will provide necessary respiratory care and services, such as oxygen therapy as ordered by physician, treatments, mechanical ventilation, tracheostomy care and/or suctioning. 4. Based upon the residents assessment, attending physician's order's, and professional standards of practice, the facility in collaboration with the resident/resident's representative will develop a care plan that includes appropriate interventions for respiratory care. 3) During an observation on 4/15/25 at 10:10 AM, Resident #36 was lying in bed. On top of bedside table there was a nebulizer mouthpiece not bagged and tubing that was not dated. (photographic evidence obtained) During an observation on 4/16/25 at 9:30 AM, Resident #36 was lying in bed. On top of bedside table there was a nebulizer mouthpiece not bagged and tubing that was not dated. Review of Resident #36's physician's orders documented no orders for respiratory therapy tubing changes. Review of Resident #36's physician's order dated 3/25/25 read, Ipratropium-Albuterol Solution 0.5-2.5 (3) MG (milligrams)/3ML (milliliters) 3 ml inhale orally every 4 hours as needed for SOB (shortness of breath) or wheezing via nebulizer. During an observation on 4/16/25 at 11:37 AM with Staff D, Registered Nurse, Unit Manager (RN UM), Resident #36 was lying in bed. A nebulizer mouthpiece was lying on top of the resident's nightstand without a bag and tubing was not dated. During an interview on 4/16/25 at 11:37 AM, Staff D, RN UM, stated, The nebulizer mouth piece should be bagged when not in use and the tubing should be dated and changed every 7 days. During an interview on 4/16/25 at 11:57 AM, the Director of Nursing (DON) stated, After use, the nebulizer mouthpiece should be stored in a bag. The tubing should be dated and changed every 7 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105304 If continuation sheet Page 9 of 18 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 04/17/2025 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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm Based on interviews and record reviews, the facility failed to ensure physician ordered laboratory services were completed for 1 (Resident #59) of 6 residents reviewed for medication regimen. Residents Affected - Few Findings include: Review of Resident #59's physician's order dated 11/13/2024, read, Lipid Panel q (every) 3 months every night shift every 3 months starting on the 13th for 1 day (s) related to Hyperlipidemia. Review of Resident #59's Health link Diagnostic Laboratories Inc dated 12/13/2024 documented lipid studies done. Review of Resident #59's laboratory results for the Month of March did not documented any laboratory services done for a Lipid Panel. During an interview on 4/16/2025 at 5:43 PM, the Director of Nursing stated, [Resident #59 name] lab was missed. It will be taken care of. Review of the policy and procedure titled Laboratory, Radiology, and other Diagnostic Services, with a last review date of 2/19/2025, read, Policy: It is the policy of this facility to ensure that laboratory, radiology, and other diagnostic services meet the needs of residents, that results are reported promptly to the ordering provider to address potential concerns and for disease prevention, provide for resident assessment, diagnosis, and treatment, and that the facility has established policies and procedures, and is responsible for the quality and timeliness of services whether services are provided by the facility or an outside resource. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105304 If continuation sheet Page 10 of 18 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 04/17/2025 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 observations, interviews, and record review, the facility failed to ensure food was safely stored, dated in a manner that preserves the nutritional value, and sanitation was maintained in the kitchen. Residents Affected - Some Findings include: A walk-through tour of the kitchen was conducted on 4/14/25 at 9:35 AM with the facility Certified Dietary Manager (CDM). During the tour observations revealed a window above the 3-compartment sink with dishes stored on sill that were not inverted with a variety of plastic containers and lids. The sill appeared to have a ledge that had black stains and cracks. Directly across the ice machine a mop, broom, dustpan alongside of 2 carts that had buildup of dirt on the top and hand bar used to transport food. The deep fryer was full of very dark dirty oil and a buildup of food particles on the deep fryer top, edges, sides and the floor underneath the fryer had a buildup of thick black/brownish substance. The cooking range had a buildup of black food particles, black buildup on stainless steel backsplash and the front of the oven had buildup on the edges. There was a stainless steel bin with a serving utensil with burnt handle sitting on top of stove. The dry pantry had a number of small, lidded bowls in a large gray bin with initials and no dates on bowls were observed. The walk in freezer had ice that dripped down the entire front, top to bottom, of the shelves. The ice was encrusted on bags and boxes. There were 2 bags of unlabeled and undated food product that was frozen solid and unable to identify the contents of blue bag. (photographic evidence) A follow-up visit to the kitchen was made on 4/15/25 at 11:00 AM. The CDM was observed 3 times grabbing paper towels to close the water faucet valve and then, proceeded to dry hands with the same paper towel that was used to close the water faucet valve. During an interview on 4/14/25 at approximately 10:00 AM, the CDM stated there should be no storage on windowsill and when stored the dishes should be inverted, mops and brooms are not supposed to be there [across from ice machine]. The deep fryer and range was last cleaned several weeks ago. The CDM further acknowledged the number of small, lidded bowls in a large gray bin were set up for tomorrows breakfast and the initials stood for the contents of cereal; however they were not dated and should be. CDM stated he had not noticed the freezer had ice dripped on shelves and food product. An interview was conducted with the Regional Dietary Manager on 4/16/25 at 8:00 AM related to expectations for the kitchen and dietary services. The Regional Dietary Manager stated that it is his expectation that the dietary manager and dietary staff follow the policies storage and labeling of food and cleaning of equipment with good sanitation practices. CDM should not be drying his hands with the same paper towel used to shut off faucet. We know we have a problem with the kitchen. The CDM is brand new. Review of the policy titled Sanitation Inspection, revised 1/1/25 and last reviewed on 2/19/25, read, Policy: It is the policy of the facility as part of the department sanitation program, to conduct inspection to ensure food service areas are clean, sanitary in compliance with applicable State and Federal regulations. Policy Explanation and Compliance Guidelines. 1. All food service areas will be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies and other insects. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105304 If continuation sheet Page 11 of 18 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 04/17/2025 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 Review of the policy titled Dietary Services - Food and Drink, revised 3/2/19 and last reviewed on 2/19/25, read, Policy: It is the policy of the facility to assure that the nutritive value of food is not compromised and destroyed because of prolonged; food storage, light and air exposure; or cooking of foods in a large volume of water; or holding on steam table. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105304 If continuation sheet Page 12 of 18 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 04/17/2025 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. Based on observations, interviews and record reviews, the facility failed to maintain complete and accurately documented medical records for 3 (Resident #84, #395, and #70) of 12 residents reviewed for skin conditions and medication management. Findings include: 1) During an observation on 4/14/2025 at 9:39 AM, Resident #84 was lying in bed, there was a dressing on Resident #84 left upper and forearm dated 4/10/2025. There was a pink gentle border dressing on Resident #84 upper right arm with no date or initials. (photographic evidence obtained) During an interview on 4/14/2025 at 9:39 AM, Resident #84 stated, I had a fall, and I got a few skin tears. During an observation on 4/16/2025 at 8:21 AM, Resident #84 was sitting up in bed eating breakfast. Resident #84's left upper and forearm had a dressing dated 4/10/2024. There was a pink gentle border dressing on Resident #84's upper right arm with no date or initials. Review of Resident #84's physician orders did not reveal any wound care orders for skin tear prior to 4/11/2025. Review of Resident #84's physician order dated 4/11/2025 read, Clean skin tears with NS (normal saline), xeroform, gauze bandage. Review of Resident #84's physician order dated 4/14/2025 read, Clean skin tears with wound cleanser, pat dry, apply xeroform to skin tear, wrap with rolled gauze 3 x week (3 times a week) and prn (as needed) every day shift every Tue, Thu, Sat (Tuesday, Thursday, Saturday) for skin tear. Review of Resident #84's Treatment Administration Record for the month of April 2025 documented dressing change for skin tear done on 4/15/2024. During an interview on 4/16/2025 at 11:13 AM with Staff B, Wound Care, License Practical Nurse (LPN), stated, I was the one who put those dressings in place [left upper and forearm dressing] on 4/10/2024. [Resident #84's Name] wound care is done three times a week. Maybe the nurse did not know he would not be seen by the wound care doctor since they are skin tears. I am not sure why he has a dressing on his upper right arm. During an interview on 4/16/2025 at 11:57 AM, the Director of Nursing stated, Nursing staff should perform wound care as per doctor's orders and document appropriately and accurately the services provided to the residents. During an interview on 4/16/2025 at 2:39 PM, Staff C , Licensed Practical Nurse, (LPN), stated, I did not do wound care on [Resident #84's Name] this Monday (4/15/2025). I thought the resident was on the wound care list to be seen by the wound care doctor. That was my mistake for not double checking to see if wound care had been done. Review of the policy and procedure titled Wound Management, with a last review date of 2/19/2025, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105304 If continuation sheet Page 13 of 18 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 04/17/2025 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 read, Policy: The purpose of this program is to assist the facility in the care, services, and documentation related to the occurrence, treatment and prevention of pressure as well as, non-pressure related wounds. Procedure: 1 .The admitting nurse/nurse identifying a skin integrity issue, will then be responsible for initiating the appropriate intervention such as ensuring treatment order(s) are in place .3. The admitting nurse will be responsible for informing the Unit Manger or other designated supervisor of the wound so that the wound can be then documented on the appropriate tracking log within benchmarks. Review of the policy and procedure titled, Documentation, with a last review date of 2/19/2025, read, Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. 2) During an observation on 4/14/2025 at 9:40 AM, Resident #395 was lying in bed; there was a single lumen PICC (peripherally inserted central catheter) line on resident's right arm with a transparent dressing dated 4/1/2025. (photographic evidence obtained) Review of Resident #395's physician's order dated 4/2/2025, read, Right anterior leg: cleanse with wound cleanser, pat dry, apply calcium alginate silver, cover with bordered gauzed as needed for soiled/displaced/wound rounds. Review of Resident #395's physician's order dated 4/2/2025, read, Right anterior leg: cleanse with wound cleanser, pat dry, apply calcium alginate silver, cover with bordered gauze every evening shift every Tue, Thu, Sat (Tuesday, Thursday, Saturday) for trauma. Review of Resident #395's physician's order dated 4/9/2025, read, Wound Care: Right anterior leg-cleanse with wound cleanser, pat dry, apply calcium alginate silver, cover with bordered gauze as needed for soiled, displaced, or wound rounds. Review of Resident #395's physician's order dated 4/9/2025, read, Wound Care: Right anterior leg: cleanse with wound cleanser, pat dry, apply calcium alginate silver, cover with bordered gauze every evening shift every Tue, Thu, Sat (Tuesday, Thursday, Saturday) for trauma wound. Review of Resident #395's physician's order dated 4/15/2025, read, Wound Care: Right anterior leg-cleanse with wound cleanser , pat dry, protect peri wound with skin prep. Apply medi honey, calcium alginate silver, cover with bordered gauze as needed for Soiled, displaced, or wound rounds. Review of Resident #395's physician's order dated 4/15/2025, read, Wound Care: Right anterior leg-cleanse with wound cleanser, pat dry, protect peri wound with skin prep. Apply medi honey, calcium alginate silver, cover with bordered gauze every evening shift every Tue, Thu, Sat for Trauma Wound. Review of Resident #395's Treatment Administrator Record for the Month of April 2025 did not document wound care treatments provided to resident. During an interview on 4/16/2025 at 11:55 AM, Staff B, Wound Care License Practical Nurse, stated, I do wound care on [Resident #395's Name] three times a day. Wound care group has their own nurse, and they are responsible for putting their orders in the system. The reason wound care is not showing in the treatment record is because they [wound care group] were not clicking to include the order in the TAR (Treatment Administration Record) they were clicking appointments. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105304 If continuation sheet Page 14 of 18 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 04/17/2025 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 3) Review of Resident #70's physician order, dated 12/12/2024, read, Midodrine HCI Oral Tablet 5mg (milligrams) give 5 mg by mouth three times a day for orthostatic hypotension [is a form of low blood pressure that happens when standing after sitting or lying down]. Review of Resident #70's Medication Administration Record (MAR) for the month of March 2025, Midodrine 5 mg was held at 0900 [9:00AM] on 4/1/2025, 4/2/2025, 4/3/2025, 4/6/2025, 4/9/2025, 4/10/2025, 4/12/2025, 4/13/2025, 4/14/2025; at 1300 [1:00PM] 4/2/2025, 4/3/2025, 4/5/2025, 4/9/2025, 4/11/2025, 4/12/2025, 4/13/2025; and at 1700 [5:00PM] on 4/1/2025, 4/2/2025, 4/3/2025, 4/4/2025, 4/7/2025, and 4/8/2025. During an interview on 4/16/2025 at 11:35 AM, Staff D, Registered Nurse, Unit Manager, stated, [Resident #70's Name] order for Midodrine should have parameters in place. During an interview on 4/16/2025 at 5:21 PM, the Director of Nursing, stated, I spoke to the provider and the medication needed to have parameters. Review of the policy and procedure titled, General Dose Preparation and Medication Administration with a last review date of 2/19/2025 read, Procedure. 4. Prior to administration record of medication, Facility staff should take all measures required by Facility policy and Applicable Law, including, but not limited to the following: 4.1.2 Confirm that the MAR reflects the most recent medication order. Review of the policy and procedure titled, Medication Administration with a last review date of 2/19/2025, read, Policy Explanation and Compliance Guidelines: 8. Obtain and record vital signs, when applicable or per physician orders. When applicable hold medication for those vital signs outside the physician prescribed parameters. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105304 If continuation sheet Page 15 of 18 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 04/17/2025 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) During the initial tour on 4/14/25 at 10:12 AM, a housekeeping aide was observed to have just left the room of Resident #62. An observation of Resident 62's room showed the floor under the sink was extremely dirty, sink was not draining, and there was no hand soap. (photographic evidence). Residents Affected - Few During an observation on 4/15/25 at 3:12 PM of Resident #62's room, the floor under sink was extremely dirty and hand soap dispenser was empty. During the observation on 4/16/25 at 8:30 AM, a housekeeping aide was observed to be on the unit where room [ROOM NUMBER] was located. Resident 62's room showed the floor under sink was extremely dirty, the sink was draining very slowly, the water was pooling in sink, and there was no hand soap in dispenser. During an interview on 4/16/25 at 8:40 AM, the Housekeeping Manager stated, The housekeeping aides are responsible for filling the soap dispensers, soap should have been replaced. During an interview on 4/16/25 at 8:43 AM, the Maintenance Director stated, The sink was fixed Monday afternoon, I see water is not draining. During an interview on 4/17/25 at 10:40 AM, the Administrator stated that they do not have a policy for soap dispensers and cannot say what the housekeepers look for when they are in the room. The soap was filled in the room once it was reported on Wednesday and she stated that she didn't know if there was a checklist for housekeepers to follow. During an interview on 4/17/25 at 10:50 AM, Staff E, housekeeping aide, with Administrator present, stated I was trained since orientation in August 2024 that when I'm cleaning a room I am to check for the soap dispenser and hand sanitizer. If the dispensers are empty we are to change them. No, there is not a check list [to follow]. We are trained to check dispensers. During an interview on 4/17/25 at 11:53 AM, Staff F, Registered Nurse (RN), Unit 2 Manager/Assistant Director of Nursing (ADON), stated If we notice that a dispenser is empty, we notify housekeeping. 4) An observation on 4/14/25 at 10:10 AM, Resident #68's Diabetasource 1.2 [prescribed nutritional tube feeding] was running at 80 milliliters (ml)/hour (hr) with flush 60 ml/hr on a pump. There was no date on tubing or water bag. (photographic evidence obtained) An observation on 4/15/25 at 8:10 AM, Resident #68's Diabetasource was running at 80 ml/hr on the pump. There was no date on tubing or water bag. An observation on 4/16/25 at 9:15 AM, Resident #68's Diabetasource was not running and the resident was still connected to the feeding. There was no date on tubing or water bag. During an interview on 4/16/25 at 9:15 AM, Staff A, Licensed Practical Nurse (LPN) stated, The tubing [for nutritional feeding] should be changed daily and dated. I don't see a date on the water bag or tubing. The feeding was just stopped to provide [Resident #68's Name] care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105304 If continuation sheet Page 16 of 18 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 04/17/2025 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 Residents Affected - Few During an interview on 4/16/25 at 10:00 AM, the Director of Nursing (DON) stated, That is unacceptable, it is nursing 101. It is a nursing standard of practice. Based on observations, interviews, and record reviews, the facility failed to ensure and maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment and to prevent the possible development and transmission of communicable diseases and infections for 3 (Resident #248, #246 and #68) of 7 residents for personal protective equipment, transmission based precautions, and tracheostomy care and 1 of 4 hallways for a sanitary environment. Findings include: 1) During an observation on 4/16/2025 at 1:50 PM, Staff D, Registered Nurse, Unit Manager, (RN UM) did not perform hand hygiene before entering Resident #246's room. Staff D donned a gown, gloves and a face shield. Staff D entered the room and removed her gloves without performing hand hygiene. Staff D removed her gloves and proceeded to put on sterile gloves. Staff D, while donning the sterile gloves, touched the sterile glove on her right hand with her left hand that did not contain a glove, breaking the sterility of the glove. After donning the Sterile gloves, Staff D proceeded to rearrange Resident #246's drawer and water cups. Staff D removed the suctioning catheter from on top the drawer which was place inside an open package for the suction catheter. Staff D began to suction Resident #246. Staff D removed all personal protective equipment and performed hand hygiene. During an interview on 4/16/2025 at 2:00 PM, Staff D, RN UM, stated, I should have performed hand hygiene before entering the room and should have been more careful with keeping sterility. I normally reuse the suction catheter throughout the shift and then when the new shift comes they get a new one. During an interview on 4/17/2025 at 8:30 AM, the Director of Nursing stated, Staff should perform hand hygiene before donning gloves or entering a patient room. Tracheostomy suctioning is a sterile procedure, and the nurse should keep one hand clean and one dirty at all times throughout the procedure. The suction catheter can be reused. Review of the policy and procedure titled, Tracheostomy Care, with a last review date of 2/19/2025 read, Policy: The facility will ensure that residents who need respiratory care, including tracheostomy care and tracheal suctioning, is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan and resident goals and preferences. Review of the policy and procedure titled, Tracheostomy Suctioning, with a last review date of 2/19/2025, read, 8. Open suction catheter kit using sterile technique and put on sterile gloves. Review of the policy and procedure titled, Infection Control-Hand Hygiene, with a last review date of 2/19/2025, read, Policy: It is the policy of the facility to perfume hand hygiene in accordance with national standards from the Centers for Disease Control and Prevention and the World Health Organizations. Procedure. 2. Alcohol Based hand rub may be used for all other hand hygiene opportunities . a. prior to caring for a resident. Review of the facility policy and procedures titled, Infection Control-Standard and Transmission-Based Precautions, with a last review date of 2/19/2025 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 communicable disease and infections in accordance with State and Federal Regulations and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105304 If continuation sheet Page 17 of 18 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 04/17/2025 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 Residents Affected - Few national guidelines. Procedure. Standard Precautions: 1. All staff are to adhere to standard precautions. b. Personal protective equipment include gloves, gown, masks, googles, and or face shield. Transmission-based Precautions.14. Contact precautions are implemented most often for residents who have infection due to an epidemiologically important organism such as multi-drug resistant organism (MDRO). a. staff are to put on gowns and gloves upon entry and remove gown and gloves upon exit of resident room. 2) During an observation on 4/14/2025 at 10:15 AM, Resident #248's room door had a contact precaution sign and personal protective equipment was observed outside of room. During an interview on 4/14/2025 at 10:23 AM, Staff C, License Practical Nurse (LPN) stated Resident #248 was on contact precautions due to a wound on his leg. During an observation on 4/14/2025 at 11:22 AM, Staff B, Wound Care LPN, entered Resident #248's room and donned gloves but did not don a gown. Staff B kneeled in front of Resident #248 and started to perform wound care on Resident #248 lower extremity. During an interview on 4/16/2025 at 11:21 AM, Staff B, Wound Care LPN stated, Resident #248 has trauma wounds on his leg. He was on enhance barrier precautions. I should have donned a gown when I was doing his wound care. I was just caught up in the moment. During an interview on 4/17/2025 at 8:30 AM, the Director of Nursing stated, The staff member came to tell me what happened. I expect staff to follow the order and don appropriate personal protective equipment when providing direct care. If resident is on contact precautions, the staff should gown before entering the room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105304 If continuation sheet Page 18 of 18