Inspection·March 20, 2024

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop and implement a baseline care plan to provide effective and person-centered care within 48 hours for 2 of 2 residents with tracheostomy, Residents #256 and #257. Findings include: Review of Resident #256's admission record showed the resident was admitted on [DATE] with the diagnoses that included acute respiratory failure with hypercapnia, pneumonia, unspecified organism, unspecified protein calorie malnutrition, generalized muscle weakness, tracheostomy status, gastrostomy status, chronic kidney disease, cerebrovascular disease, generalized anxiety disorder, adult failure to thrive, and essential primary hypertension. Review of Resident #256's medical record revealed no care plan or care planned interventions related to tracheostomy. Review of Resident #257's admission record showed the resident was admitted on [DATE] with diagnoses that included cerebral infarction (stroke), acute respiratory failure with hypoxia (low oxygen levels in body tissues), chronic systolic (congestive) heart failure, Alzheimer's disease, tracheostomy status (a surgical opening in the neck for a tube to provide an airway and remove secretions from the lungs), and seizures. Review of Resident #257's medical record revealed no care plan or care planned interventions related to tracheostomy, oxygen, and suctioning needs. During an interview on 3/19/2024 at 8:22 AM, the Director of Nursing stated, I do not see a baseline care plan with interventions related to the trach [tracheostomy]. During an interview on 3/20/2024 at 9:45 AM, Staff I, Licensed Practical Nurse (LPN), stated, There is no baseline care plan in PCC [point click care] for the tracheostomy. I usually document it on paper and do a comprehensive within 21 days. I did not have this completed. We should do a baseline and it would be important for the care for the trachs. Review of the facility policy and procedures titled Baseline Care Plan with the last approval date of 12/29/2023 read, Procedure: The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet the professional standards of quality care. The baseline care plan will: 1. Be developed within 48 hours of a resident's admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105308 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 105308 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2024 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 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 record review and interview, the facility failed to ensure residents who required long-acting insulin received insulin per physician orders for 2 of 6 residents reviewed for unnecessary medications, Residents #17 and #60. Residents Affected - Few Findings include: 1. Review of Resident #17's admission record showed the resident was admitted on [DATE] with the diagnoses that included metabolic encephalopathy, diabetes mellitus due to underlying condition with hyperosmolarity without nonketotic hyperglycemic hyperosmolar coma (a serious complication of diabetes mellitus with high blood sugar levels and dehydration), unspecified atrial fibrillation (an irregular heartbeat), acute kidney failure, peripheral vascular disease, hyperlipidemia, and chronic venous hypertension. Review of Resident #17's physician order dated 1/10/2024 read, Order Summary: Insulin Glargine Subcutaneous Solution Pen-injector 100 unit/ml [milliliter] (Insulin Glargine) Inject 12 unit subcutaneously at bedtime for DM [diabetes mellitus] Order Summary: May check glucose PRN [as needed] if exhibiting sx [symptoms] of Hypo [low] or Hyper [high] Glycemia [blood sugar] as needed for sx of Hypo or Hyper glycemia Call MD [Medical Doctor] if BS [blood sugar] is < 60 or > 500. Review of Resident #17's Medication Administration Record (MAR) for February 2024 for administration of Insulin Glargine revealed the MAR was coded as 13 (glucose out of parameters) on 2/12/2024 at 9:00 PM, and coded as 10 (vitals out of parameters) on 2/20/2024, 2/28/2024, and 2/29/2024 at 9:00 PM. Review of Resident #17's progress notes dated 2/28/2024 at 10:03 PM showed a medication administration note reading, Held due to glucose 49. Review of Resident # 17's progress notes from 2/12/2024 through 2/29/2024 revealed no physician notification of insulin being held and blood sugar of 49, no recheck of blood sugar on 2/28/2024 after blood sugar of 49, no assessment for signs and symptoms of hypoglycemia and no treatment for blood sugar of 49. Review of Resident #17's MAR for March 2024 for administration of Insulin Glargine revealed the MAR was coded as 13 on 3/5/2024 and 3/11/2024 at 9:00 PM, and coded as 10 on 3/12/2024 and 3/15/2024 at 9:00 PM. Review of Resident #17's progress notes from 3/1/2024 through 3/17/2024 revealed no physician notification of insulin being held. During an interview on 3/19/2023 at 10:51 AM, the Director of Nursing (DON) verified that the insulin was documented as held and stated, Long-acting insulin should not be held and does not have any parameters to hold it. When her [Resident #17's] blood sugar was 49, I do not see any repeat blood sugars documented. There should be a recheck of blood sugar when below 60. We do have orders for hypoglycemia in place and should have called the doctor. I don't see any notes documenting he [the doctor] was notified. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105308 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 105308 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm During a telephone interview on 3/19/2024 at 10:57 AM, Staff F, Registered Nurse (RN), stated, I did hold these insulins on [Resident #17's name]. She is a brittle diabetic and I remember at least once that it was like 49 and I held it. It [the insulin] does not have any parameters to hold it, but I still held it. That's a nursing judgement call. I did not call or let the doctor know. I should have called when her blood sugar was below 60. Residents Affected - Few During a telephone interview on 3/19/2024 at 11:33 AM, Staff B, Licensed Practical Nurse (LPN), stated, If I held the medication it was because her blood sugar was out of range. It was too low to give. We do have parameters to hold insulin, so that's what I did. Long-acting insulin should be held when the blood sugars are below 150 like the orders say. I should have a note if I called the doctor. 2. Review of Resident #60's admission record showed the resident was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus with unspecified complications, acquired absence of right leg below knee, acute kidney failure, and essential primary hypertension. Review of Resident #60's physician order dated 12/1/2023 read, Insulin Aspart Solution, Inject as per sliding scale. Review of Resident #60's physician order dated 2/1/2024 read, Lantus Solution 100 unit/ml (Insulin Glargine), Inject 20 units subcutaneously one time a day related to type 2 diabetes mellitus with unspecified complications. Review of Resident #60's MAR for February 2024 for administration of Insulin Aspart revealed no documentation on 2/7/2024, 2/8/2024 and 2/11/2024 at 10:00 PM. Further review of the MAR for administration of Lantus Solution revealed no documentation on 2/7/2024 and on 2/11/2024 at 9:00 PM. Review of Resident #60's MAR for March 2024 for administration of Lantus Solution revealed the MAR was coded as 2 (drug refused) on 3/1/2024 and 3/7/2024 at 6:00 AM, and coded as 9 (other/see notes) on 3/6/2024. Review of Resident #60's nursing progress note dated 3/1/2024 read, Patient refused Lantus 20 units stating she didn't want to take it because she is concerned it will drop her blood sugar to low. This writer explained to patient how long acting insulin worked. Patient stated she understood but still did not want to take it at this time. Review of Resident #60's progress notes from 3/1/2024 through 3/17/2024 revealed no physician notification of insulin being held. During an interview on 3/19/2024 at 10:53 AM, the DON verified that insulin was held and documented as held and there were blanks on the MAR for Resident #60 and stated, There seems to be no documentation for when or if the insulin was given and there are some drug refusals. I expect the nurses to document that they notified the doctor or on call when this happens. During a telephone interview on 3/19/2024 at 11:52 AM, the Medical Doctor (MD) stated, The staff should notify us when they are holding insulin. Long-acting insulin typically doesn't have orders to hold, but we may need to discuss this as an option to get that done in the future. I would expect nurses to use some type of judgement to hold when the blood sugars are below 60 and a patient is symptomatic. I do expect orders to be followed. I don't think as I review that there was any true harm or potential for any adverse consequences in having held these medications. I should be notified if (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105308 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 105308 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few patients are refusing their insulin, so I can speak with them and educate them about the risks of refusing and make a treatment plan they will stick to. I do want staff to notify us when they are holding medications. During an interview on 3/20/2024 at 6:08 AM, Staff G, LPN, stated, I did hold her [Resident #60's] insulin. She refused it. I should have called the doctor, but no I did not. She does sometimes refuse her long-acting insulin when she thinks her blood sugar is too low. Review of the facility policy and procedure titled Diabetes Management with an approval date of 12/29/2023 read, Policy: It will be the policy of this facility to provide appropriate care to residents with diabetes mellitus. Nursing measures and physician orders will be implemented to minimize the risk of hypo/hyperglycemia. Procedure: 1. Residents diagnosed with diabetes mellitus (or other condition requiring blood glucose monitoring and control) will receive insulin, oral hypoglycemic medications and/or an individually prescribed diet according to physician order . 5. Staff will provide glucose monitoring, medication administration, laboratory testing and diet per physician orders . 7. Staff should report signs and symptoms of hypoglycemia to the physician. Many residents receiving insulin and oral hypoglycemic have parameters as to when the physician should be notified . 10. Nursing interventions, per physician orders, may vary for residents experiencing hypoglycemia depending on the severity and symptoms of the resident as residents' behavior is different depending on their sensitivity to hypoglycemia. Responsive residents that are able to swallow may receive juice or other rapidly absorbed glucose as an intervention. Responsive residents that are unable to swallow or unresponsive residents may receive oral glucose paste to buccal mucosa, intramuscular glucagon, or IV 50% dextrose and notify the physician for further orders . 13. Report non compliance with physician orders to the physician and/or resident representative, if applicable. 14. Document pertinent information regarding medication administration, changes in condition, education or interventions in clinical record. Review of the facility policy and procedure titled 6.0 General Dose Preparation and Medication Administration with the last revision date of 1/1/2022 and the last approval date of 12/29/2023 read, Applicability: The Policy 6.0 sets forth the procedures relating to general dose preparation and medication administration. Facility staff should also refer to Facility policy regarding medication administration and should comply with Applicable Law and the State Operations Manual when administering medications. Procedure . 6. After medication administration, Facility staff should take all measures required by Facility policy and Applicable Law, including, but not limited to the following: 6.1 Document necessary medication administration/treatment information (e.g., when medications are opened, when medications are given, injection site of a medication, if medications are refused, PRN medications, application site) on appropriate forms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105308 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 105308 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to ensure resident rooms were free of accident hazards for 1 of 3 residents reviewed for accidents, Resident #76. Residents Affected - Few Findings include: During an observation on 3/17/2024 at 9:37 AM, there was an open can of green beans at Resident #76's bedside with a sharp metal edge exposed. Approximately 3/4 of the sharp lid was bent backwards and approximately 1/4 of the lid remained intact. During an interview on 3/17/2024 at 9:38 AM, Resident #76 stated she had opened the can with her can opener the night before. When asked if she had ever cut or injured herself on the open can or with the can opener, Resident #76 stated, I have not yet. During an interview on 3/17/2024 at 9:45 AM, the Director of Nursing (DON) confirmed that the can of green beans had exposed metal edge and should not have been there and could be a danger. Review of Resident #76's physician order dated 11/21/2023 read, Eliquis Oral Tablet 5 MG [milligram] (Apixaban), Give 5 mg by mouth two times a day for a fib. Review of Resident #76's care plan initiated on 8/24/2023 read, Focus: [Resident #76's name] is at risk for abnormal bleeding, hemorrhage, and bruising related to anticoagulant use for atrial fibrillation. During an interview on 3/18/2024 at 1:15 PM, the Social Services Director (SSD) stated she did not personally buy canned foods for Resident #76; however, the grandson of Resident #76 brings in food for her all the time. When asked if she was aware that Resident #76 had a personal can opener in her room that she used to open cans of food, the SSD stated she was unaware of this, and residents should not have can openers in their room as the can opener could pose a risk of getting cut or injured. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105308 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 105308 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2024 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 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** Based on observation, interview, and record review, the facility failed to ensure residents received respiratory care consistent with professional standards of practice for 1 of 3 residents reviewed for respiratory care, Resident #257. Residents Affected - Few Findings include: Review of Resident #257's admission record showed the resident was admitted on [DATE] with diagnoses that included cerebral infarction (stroke), acute respiratory failure with hypoxia (low oxygen levels in body tissues), chronic systolic (congestive) heart failure, Alzheimer's disease, tracheostomy status (a surgical opening in the neck for a tube to provide an airway and remove secretions from the lungs), and seizures. Review of Resident #257's physician order dated 3/15/2024 read, Trach- Encourage and assist resident with us of humidified oxygen 28%/5 liters via trach collar every shift. During an observation on 3/17/2024 at 3:17 PM, Resident #257 had a tracheostomy collar mask with no humidification, and the oxygen concentrator was set on 4 liters per minute. Review of Resident #257's physician order dated 3/18/2024 read, Trach- Encourage and assist resident with us of humidified oxygen 28% via trach collar every shift. During an observation on 3/18/2024 at 1:28 PM, Resident #257 had a tracheostomy mask collar, and the oxygen concentrator was set on 3 liters per minute. During an observation on 3/19/2024 at 7:41 AM, Resident #257 had a tracheostomy mask collar and the oxygen concentrator was running at 3 liters per minute. During an interview on 3/19/2024 at 8:11 AM, Staff C, Licensed Practical Nurse (LPN), confirmed that oxygen was running at 3 liters and stated, I honestly have not seen an oxygen order for 28%. It's usually set at liters, not a percent. I don't know how many liters of oxygen make 28% by the trach collar. During an interview on 3/19/2024 at 8:22 AM, the Director of Nursing (DON) stated, The oxygen should run at whatever the order calls for. I don't know if the staff know what liters per minute make 28% oxygen. The concentrator should not be at 3, 4 or 5 liters. The oxygen should be set at 2 liters per minute. I expect staff to follow doctor's orders for oxygen. Review of the facility policy and procedure titled Tracheostomy Care and Suctioning/Oxygen with the last approval date of 12/29/2023, read, Policy: The facility will ensure that residents who need respiratory care, including tracheostomy care and tracheal suctioning, is provided care consistent with professional standards of practice, the comprehensive person-centered care plan and resident goals and preferences. Procedures . 2. The facility will provide necessary respiratory care and services, such as oxygen therapy as ordered by the physician, treatments, mechanical ventilation, tracheostomy care and/or suctioning. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105308 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 105308 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medications were labeled and stored in accordance with currently accepted professional principles in 4 of 4 medication carts reviewed for medication storage. Findings include: During an observation on [DATE] at 8:35 AM, Medication Cart #1 was unlocked and unattended. There were two residents walking by the medication cart. Staff B, Licensed Practical Nurse (LPN), returned to the medication cart at 8:38 AM. The medication cart was unattended and unlocked for three minutes. During an interview on [DATE] at 8:38 AM, after coming back to the medication cart, Staff B, LPN, stated, I shouldn't have done that, but I wasn't really gone that long. During an observation of Medication Cart #1 on [DATE] at 8:38 AM with Staff B, LPN, there were two opened Novolog insulins with no date opened or expiration date, one opened Lantus insulin with no date opened or expiration date, and one opened bottle of artificial tears with no date opened or expiration date. During an interview on [DATE] at 8:39 AM, Staff B, LPN, stated, All insulin should have the date opened and expiration dates. I don't know when eye drops expire. During an observation of Medication Cart #2 on [DATE] at 8:40 AM with Staff C, LPN, there were one opened Lispro insulin pen with no date opened or expiration date, one opened bottle of Latanoprost eye drops with no date opened or expiration date, one unopened Latanoprost eye drops with pharmacy instructions to refrigerate until opened, and two unopened insulin glargine pens with pharmacy instructions to refrigerate until opened. During an interview on [DATE] at 8:45 AM, Staff C, LPN, stated, We should not have the unopened eye drops or insulin on the cart. We should date them when we get them. All insulin and eye drops should have dates on them. During an observation of Medication Cart #3 on [DATE] at 8:55 AM with Staff D, Registered Nurse (RN), there were one opened Lispro insulin with no date opened or expiration date, one unopened Lantus insulin with pharmacy instructions to refrigerate until opened, one opened Lantus insulin with no date opened or expiration date, and one opened Lispro insulin with an expiration date of [DATE]. During an interview on [DATE] at 9:05 AM, Staff D, RN, stated, All insulin should be labeled with the date opened or when they expire. We should not have the insulin that is expired on the cart, and we should keep the insulin in the refrigerator until we need to use it. During an observation of Medication Cart #4 on [DATE] at 9:12 AM with Staff E, LPN, there were one unlabeled, undated medication cup with eleven pills, one opened Basaglar insulin with no date opened or expiration date, and one opened insulin glargine with an expiration date of [DATE] and pharmacy (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105308 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 105308 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2024 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 0761 instruction to use within 28 days. Level of Harm - Minimal harm or potential for actual harm During an interview on [DATE] at 9:20 AM, Staff E, LPN, stated, I should not pre-pour medications. The expired insulin should not be on the cart. I didn't know it was there. All insulins should be labeled when opened and when it expires. Residents Affected - Many During an interview on [DATE] at 7:50 AM, the Director of Nursing (DON) stated, No medications should ever be pre-poured. Insulin should be dated and if expired taken off the cart. Insulin and eye drops that need to be kept in the refrigerator, should be kept there. Review of the facility policy and procedure titled 6.0 General Dose Preparation and Medication Administration with the last revision date of [DATE] and the last approval date of [DATE] read, Applicability: The Policy 6.0 sets forth the procedures relating to general dose preparation and medication administration. Facility staff should also refer to Facility policy regarding medication administration and should comply with Applicable Law and the State Operations Manual when administering medications. Procedure . 3. Dose Preparation: Facility should take all measures required by Facility policy and Applicable Law, including, but not limited to the following . 3.10 Facility staff shall not leave medications or chemicals unattended . 3.12. Facility staff should enter the date opened on the label of the medications with shortened expiration dates (e.g., insulins, irrigation solutions, etc.) . 7. Facility should ensure that medication carts are always locked when out of sight or unattended. Review of the facility policy and procedures titled 5.3 Storage and Expiration Dating of Medications, Biologicals with the last approval date [DATE] read, Applicability: This Policy 5.3 sets forth the procedures relating to the storage and expiration dates of medications, biologicals, syringes, and needles. Procedure . 4. Facility should ensure that medications and biologicals that are: (1) have an expiration date on the label, (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier. 5. Once any medication or biological package is opened, Facility should follow manufacturer/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. 5.1 Facility staff may record the calculated expiration date based on date opened on the primary medication container . 5.4 When an ophthalmic solution or suspension has a manufacturers shortened beyond use date once opened, facility staff should record the date opened and the date to expire on the container . 10. Facility should ensure that medications and biologicals are stored at their appropriate temperatures according to the United States Pharmacopeia guidelines for temperature ranges. Facility staff should monitor the temperature of vaccines twice a day . 10.2 Refrigeration 36° to 46° F or 2° to 8°C. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105308 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 105308 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 ensure food was safely and properly stored and labeled in the areas of kitchen reach-in cooler, and the reach-in, and walk-in freezer, failed to ensure the kitchen equipment were kept clean, and failed to ensure dietary staff had hair covering while in the kitchen area. Findings include: During an observation while conducting a walk-through tour of the kitchen with the Charge [NAME] on 3/17/2024 at 9:02 AM, the Charge [NAME] and Staff A, Dietary Aide, had no hair covering. There were several containers of unidentifiable food items in the reach-in cooler without an identifying label or date. There were several items including a large metal mixing bowl partially covered with contents spilling out onto other items, a tray with six individual dessert type food, and an open plastic bag of egg type product in the reach-in freezer without an identifying label or date. There was a large buildup of ice around the door and on the ice curtain of the walk-in freezer. There were several boxes remaining on the floor of the walk-in freezer. During an interview on 3/17/2024 at 9:15 AM, the Charge [NAME] confirmed that the items in the reach-in cooler and reach-in freezer did not have an identifying label or date and should have been labelled and dated before storing. The Charge [NAME] confirmed the items on the floor of the freezer and the ice buildup around the door and on the ice curtain and stated it was due to the door not being closed properly. The Charge [NAME] stated the truck delivery date was on Tuesdays and the food should have been put away and not left remaining on the floor of the freezer. The Charge [NAME] confirmed that she and Staff A were not wearing proper hair covering. During an interview on 3/17/2024 at 9:16 AM, Staff A, Dietary Aide confirmed he was not wearing a hairnet or a beard guard. During the follow up tour of the kitchen on 3/18/2024 at 5:45 AM, there were food items already placed on the tray line at 5:49 AM. There was a large buildup of food bits and dried debris on the countertop can opener. During an interview on 3/18/2024 at 5:50 AM, the Charge [NAME] stated that she had placed the food on the tray too early and should not be there until 30 minutes prior to tray service. During an interview on 3/18/2024 at 8:42 AM, the Certified Dietary Manager (CDM) stated it was her expectation that all policies and training were followed. The CDM stated that all dietary staff were required to wear hair coverings while working in the department. The CDM stated it was her expectation that all leftover foods were labelled and dated before being stored. The CDM stated that the equipment, including the can opener, should be cleaned daily. Review of the facility policy and procedures titled Personal Appearance last reviewed on 3/19/2024, read, 3. Hair cover is to be worn by any/all staff working with food in the kitchen. Review of the facility policy and procedures titled Food Storage dated October 1, 2019 and last reviewed on 3/19/2024, read, Procedure . 2. Refrigerators . d. Date, label, and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage . 3. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105308 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 105308 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2024 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 0812 Freezers . c. Store all foods on racks or shelves off the floor . e. Store frozen foods in moisture-proof wrap or containers that are labeled and dated. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105308 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 105308 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2024 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 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 ensure staff performed hand hygiene during medication administration to prevent from possible spread of infection and communicable diseases in 3 of 4 medication administration observations. Residents Affected - Few Findings include: During an observation on 3/19/2024 at 8:50 AM, Staff J, Licensed Practical Nurse (LPN), returned to the medication cart after administering medications to a resident. Without performing hand hygiene, Staff J prepared Resident #34's medications and administered the medications to the resident. At 9:01 AM, Staff J returned to the medication cart, prepared Resident #10's medications, and administered the medications to the resident. At 9:04 AM, Staff J returned to the medication cart. Staff J prepared Resident #11's medications and administered the medications. During an interview on 3/19/2024 at 9:15 AM, Staff J, LPN, stated, I should have used hand sanitizer before and after getting the meds to the residents. I don't know why I didn't. During an interview on 3/19/2024 at 2:15 PM, the Director of Nursing (DON) stated, All medication policies should be followed. Hand washing should be done with all medication administration and staff should follow policies and procedures. Review of the facility policy and procedure titled 6.0 General Dose Preparation and Medication Administration with the last revision date of 1/1/2022 and the last approval date of 12/29/2023 read, Applicability: The Policy 6.0 sets forth the procedures relating to general dose preparation and medication administration. Facility staff should also refer to Facility policy regarding medication administration and should comply with Applicable Law and the State Operations Manual when administering medications. Procedure . 2. Prior to preparing or administering medications, authorized and competent Facility staff should follow Facility's infection control policy (e.g., hand washing). Review of the facility policy and procedures titled Hand Hygiene with the last approval date of 12/29/2023 read, Policy: This facility considers hand hygiene the primary means to prevent the spread of infections. Procedure . 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . 5. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations . c. Before preparing or handling medications. Review of the facility policy and procedures titled Infection Control- Medication Administration with the last approval date of 12/29/2023 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105308 If continuation sheet Page 12 of 12