Inspection·November 9, 2022

F 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to ensure the binding arbitration agreements explicitly granted the resident or his or her representative the right to rescind the agreement within 30 calendar days of signing it for to 3 of 3 reviewed residents, Residents #29, #100, and #152. Residents Affected - Many Findings include: Review of Voluntary Binding Arbitration Agreement presented to Resident #29 on 10/10/2022 reads, F. RIGHT TO CHANGE YOUR MIND: This Agreement may be cancelled by written notice sent certified mail, return receipt requested, to the Facility's Administrator within fifteen (15) calendar days of the Resident's date of admission. If alleged acts underlying the dispute are committed prior to the cancellation date, this Agreement shall be binding with respect to said alleged acts. If not cancelled in writing, this Agreement shall be binding on this admission and all of the Resident's other admissions to Avante without any need for further renewal. Review of Voluntary Binding Arbitration Agreement presented to Resident #100 on 10/10/2022 reads, F. RIGHT TO CHANGE YOUR MIND: This Agreement may be cancelled by written notice sent certified mail, return receipt requested, to the Facility's Administrator within fifteen (15) calendar days of the Resident's date of admission. If alleged acts underlying the dispute are committed prior to the cancellation date, this Agreement shall be binding with respect to said alleged acts. If not cancelled in writing, this Agreement shall be binding on this admission and all of the Resident's other admissions to Avante without any need for further renewal. Review of Voluntary Binding Arbitration Agreement presented to Resident #152 on 11/2/2022 reads, F. RIGHT TO CHANGE YOUR MIND: This Agreement may be cancelled by written notice sent certified mail, return receipt requested, to the Facility's Administrator within fifteen (15) calendar days of the Resident's date of admission. If alleged acts underlying the dispute are committed prior to the cancellation date, this Agreement shall be binding with respect to said alleged acts. If not cancelled in writing, this Agreement shall be binding on this admission and all of the Resident's other admissions to Avante without any need for further renewal. During an interview on 11/8/2022 at 12:51 PM, the Acting Administrator confirmed the facility's arbitration agreement had not yet been revised to include explicitly granting the resident or his or her representative the right to rescind the agreement within 30 calendar days of signing it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105308 If continuation sheet Page 2 of 3 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 105308 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at Inverness Inc 304 S Citrus Ave Inverness, FL 34452 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 0851 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Based on record review and interview, the facility failed to comply with mandatory submission of staffing information based on payroll data in a uniform format at least quarterly for Quarter 3 2022 (April 1- June 30). Findings include: Review of the facility's Payroll Based Journal report dated 11/3/2022 revealed the facility failed to submit staffing information within the timeline requirements for Quarter 3 of 2022 (April 1- June 30). During an interview on 11/9/2022 at 12:32 PM, the Acting Administrator confirmed that the Payroll Based Journal data was not submitted by the corporate office for Quarter 3 of 2022 (April 1- June 30). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105308 If continuation sheet Page 3 of 3