Inspection·December 4, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on record review and staff interviews, the facility failed to develop and implement a comprehensive, person-centered care plan that addressed the resident's medical, physical, mental, and psychosocial needs for 1 (Resident #27) of 4 residents reviewed for comprehensive care planning. Findings include:Record review of Resident #27's November 2025 Medication Administration Record (MAR) revealed 28 documented refusals of physician-ordered medications.Record review of Resident #27's December 2025 MAR revealed an additional 28 documented refusals of physician-ordered medications.Review of the resident's care plan revealed no problem statement, goals, or individualized interventions addressing repeated refusal of medications, despite the ongoing pattern of refusals across two consecutive months.During an interview with the Director of Nursing (DON) on 12/4/2025 at 9:50 AM, she stated that Resident #27 should be care planned for refusal of medications, confirming that the care plan did not reflect this clinically relevant issue. Event ID: Facility ID: 105333 If continuation sheet Page 2 of 26 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 105333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at MT Dora, Inc 3050 Brown Ave Mount Dora, FL 32757 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 interview and record review the facility failed to administer insulin as ordered for 2 (Resident #2 and Resident #3) of 7 residents reviewed for medication administration and failed to provide wound care as ordered for 2 (Resident #36 and Resident #88) of 4 residents reviewed for pressure ulcers.Findings include:1) Review of Resident #2's physician order dated 10/6/2025 read, Lantus Subcutaneous Solution 100 Unit/ML [Unit per milliliter] (Insulin Glargine) Inject 10 unit subcutaneously one time a day for Hyperglycemia.Review of Resident #2's physician order dated 11/4/2025 read, Lantus Subcutaneous Solution 100 Unit/ML (Insulin Glargine) Inject 12 unit subcutaneously one time a day for Hyperglycemia.Review of Resident #2's Medication Administration Record for the month of November 2025 for Lantus 100 Unit/ML inject 10 units documented on 11/2/2025 at bedtime coded 13 [Glucose out of Parameters].Review of Resident #2's Medication Administration Record for the month of November 2025 for Lantus 100 Unit/ML inject 12 units documented at bedtime code 13 on 11/15/2025, 11/16/2025, 11/22/2025, and 11/24/2025.During an interview on 12/3/2025 at 11:59 AM Physician Assistant #1 stated, I have not gotten phone calls regarding staff holding [Resident #2's name] insulin. Communication and reporting is a big deal here. I have parameters in place for a reason. I want to be notified. I don't need a phone call every time but until we have trust and a pattern I want the staff to call me, but a lot of times they do not. [Resident #2's name] has not run into any danger, it is not a big issue.During an interview on 12/3/2025 at 12:57 PM, the Director of Nursing stated, I expect nurses to use their nursing judgment but always communicate with the provider and follow physician orders. If they are using their nursing judgment they should call the provider and get clarification.Review of the facility policy and procedure titled Physician Services with a last review date of 1/28/2025 read, 8. All physician orders will be followed as prescribed and if not followed, the reason shall be recorded on the resident's medical record during that shift.2) Review of Resident #3's physician order dated 9/28/2025, read, Insulin Lispro Prot & Lispro Subcutaneous Suspension (75-25) 100 Unit/ML (Insulin Lispro Protamine & Lispro) Inject 16 units subcutaneously two times a day for Hyperglycemia (Before breakfast and bedtime).Review of Resident #3's physician order dated 11/30/2025, read, Insulin Lispro Prot & Lispro Subcutaneous Suspension (75-25) 100 UNIT/ML (Insulin Lispro Protamine & Lispro) Inject 16 units subcutaneously one time a day for DM [Diabetes Mellitus].Review of Resident #3's physician order dated 11/2/2025, read, Hold insulin if blood sugar is less than 90 every shift.Review of Resident #3's Medication Administration Record for the month of November 2025 for Insulin Lispro Protamine and Lispro documented at 2100 [9:00 PM] on 11/1/2025 blood sugar level 114 coded 13, on 11/16/2025 blood sugar level 112 coded 13, and on 11/22/2025 blood sugar level 138 coded 13 [Glucose out of Parameters].During an interview on 12/3/2025 at 4:53 PM, Physician #1 stated, I don't recall notification from staff regarding [Resident #3's name]. Resident #3 has not had any medical emergencies regarding her diabetic management.3) During an observation on 12/01/2025 at 9:34 AM, Resident #88 was lying in bed. Resident #88 right lower foot was wrapped with Kerlix Gauze secured with tape dated 11/27/2025 [Staff F initials]. [photographic evidence obtained]Review of Resident #88's physician order dated 11/20/2025 read, Wound Care: Right Heel-Skin prep, cover with ABD [abdominal] pad and wrap with kerlix. Secure with tape every day shift for unstageable pressure injury and as needed for soiled /displaced/wound rounds.During an interview on 12/3/2025 at 10:16 AM, Staff G, Licensed Practical Nurse, stated, I do not really recall. I remember doing something on Saturday [11/29/2025] with [Resident #88's name] right lower leg. I just cannot remember. If there is a check in the system it means it was completed.During an interview on 12/3/2025 at 12:56 PM, the Director of Nursing stated, Wound care should be done as per physician orders.Review of the facility policy and Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105333 If continuation sheet Page 3 of 26 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 105333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at MT Dora, Inc 3050 Brown Ave Mount Dora, FL 32757 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 FORM CMS-2567 (02/99) Previous Versions Obsolete procedure titled Wound Management with a last review date of 1/28/2025 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.4) During an observation on 12/01/2025 at 10:07 AM, Resident #36 was lying in bed, right foot was wrapped with gauze secured by tape dated 11/27 [Staff F initials]. Dressing was loosened in the heel area and soiled.Review of Resident #36's physician order dated 11/20/2025,, read, Wound Care: Right heel-cleanse with Dakin's 1/2 str. Sol [strength solution]. pat dry. Skin prep peri wound. Apply calcium alginate, cover with ABD pad, wrap with rolled gauze secure with tape every day shift for unstageable pressure ulcer.Review of Resident #36's physician order dated 10/17/2025 read, Wound care: Right lateral foot-skin prep, offload every day shift for arterial ulcer.Review of Resident #36's physician order dated 11/20/2025, read, Wound Care: Right 2nd toe-cleanse with Dakin's 1/2 str. Sol, pat dry. Skin prep peri wound, apply calcium alginate cover with ABD pad, wrap with rolled gauze, secure with tape every day shift for DM [Diabetic] Ulcer.Review of Resident #36's physician order dated 11/20/2025, read, Wound Care: Right lateral great toe cleanse with Dakins 1/2 str. Sol pat dry. Skin prep peri wound. Apply calcium alginate cover with ABD pad, wrap with rolled gauze, secure tape every day shift for arterial ulcer.Review of Resident #36's physician order dated 11/20/2025, read, Wound Care: Right Lateral heel-cleanse with Dakin's 1/2 str. Sol, pat dry skin prep peri wound. Apply calcium alginate cover with ABD pad, wrap with rolled gauze, secure with tape every day shift for arterial ulcer.During interview on 12/3/2025 at 10:16 AM, Staff G, LPN, stated, I might have check off the wound care and sometimes you might forget. I am wondering if it was supposed to get done by the wound care nurse, so I checked it off and it didn't get done.During an interview on 12/4/2025 at 6:54 AM with the DON stated, I spoke to the nurses, and they stated they had checked it off [wound care] and would do the wound care later and they forgot. I expect them to check off on a treatment once it is completed.During an interview on 12/4/2025 at 11:50 AM with Staff H, LPN, stated I don't remember without looking at the record. If the nurse assigned to wound care is not able to do the wound care they will let the nurses on the cart know to do the wounds. I don't remember what happened.Review of the facility policy and procedure titled Clean Dressing Change with a last review date of 1/28/2025 read, Policy: It is the policy of the facility to ensure change dressings in accordance with the state and federal regulations, and national guidelines. Event ID: Facility ID: 105333 If continuation sheet Page 4 of 26 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 105333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at MT Dora, Inc 3050 Brown Ave Mount Dora, FL 32757 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 Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 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 facility failed to safely use a mechanical lift for 1 (Resident #99) of 2 residents reviewed for accidents.Findings include:During an observation on 12/01/2025 at 9:40 AM, Staff E, Certified Nursing Assistant (CNA) entered Resident #99's room with a Hoyer lift. Resident #99 was observed on the Hoyer lift with only Staff E in the room. Resident #99 was hanging in the Hoyer lift completely off bed on left side parallel to the bed with the floor beneath resident's bottom and legs. Staff E was making the residents bed standing next to Resident #99.Review of Resident #99's care plan initiated on 10/4/2021, read, [Resident #99's name] has a chronic ADL [activities of daily living] self-care performance deficit resulting from the physical effects of muscle weakness, impaired balance /coordination and historical expressions of pain with non-ambulatory status. Interventions: is dependent upon staff for transfers with 2 person via HOYER lift.During an interview on 12/1/2025 at 9:49 AM, Staff E, CNA, stated, I know the Hoyer lift should be used with two people at all times. I was trying to change the linen on her [Resident #99] bed. I was not going to transfer her. Staff E confirm resident was hanging on the Hoyer lift off the bed with the floor underneath the resident. Staff E stated, I am sorry.During an interview on 12/3/2025 at 10:31 AM, the Director of Nursing stated, A Hoyer lift should be used with two staff members at all times.During an interview on 12/3/2025 at 11:10 AM, the Director of Therapy and Rehabilitation stated, The protocol to use a Hoyer is 2 person at all times. Upon hire, staff are trained using videos that are sent by the company that makes the Hoyer. It is important to always have two person assist when using the Hoyer in case something goes wrong you have an extra set of hands. Let's say the Hoyer fails or a strap is not on correctly, something could happen. By having two people you will not be by yourself. Review of the facility policy and procedure titled Safe Resident Handling /Transfers with a review date of 1/28/2025 read, Policy: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risk for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. Policy Explanation: 10. Two staff members must utilize when transferring resident with a mechanical lift. Event ID: Facility ID: 105333 If continuation sheet Page 5 of 26 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 105333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at MT Dora, Inc 3050 Brown Ave Mount Dora, FL 32757 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to provide nutritional services for 2 (Resident #30 and Resident #66) of 5 resident review for dietary services.Findings include:1) Review of Resident #30's weights documented on 07/15/2025, the resident weighed 189 lbs [pounds]. On 11/04/2025, the resident weighed 164 lbs, which is a -13.23% Loss.Review of Resident #30 dietary progress note dated 11/18/2025 read, Summary: Resident show fair appetite. Weight on downward trend stabilizing with fortified foods with meals and shakes. Resident is on medication that cause edema. Liberalized diet intervention in place to promote po [by mouth] intakes nutrition interventions in place to avoid significant wt [weight] loss. Goals: avoid significant wt changes, po intake >76% as tolerated, 100% supplements, skin remains intact. Recommend: continue fortified foods with meals and health shakes x 30 days. Continue to monitor wt, skin labs, and po intakes as appropriate.Review of Resident #30's physician orders did not document an active order for health shakes after 11/23/2025.Review of Resident #30's Medication Administration Record for the month of November 2025 did not document health shakes after 11/23/2025.Review of Resident #30's Medication Administration Record for the month of December 2025 did not document health shakes administration.During an interview on 12/3/2025 at 1:05 PM, the Registered Dietician stated, [Resident #30's name] is receiving palliative care and weight loss is unavoidable. She is receiving house shakes and not improving. I would consider comfort measures for her. I send an email to the Director of Nursing at an end of day and then the recommendations get approved. I don't see the health shakes in her record; they should have been added. I thought she was receiving them. I believe her weight loss is due to the condition of her health because health shakes are only once a day and only provide 200 calories which would not be substantial. I am not sure how the health shakes didn't get put on there.During an interview on 12/3/2025 at 3:15 PM, the Director of Nursing stated, The Registered Dietitian puts in here own orders into the system. She does send an email, but she is the one putting the orders in herself.During an interview on 12/4/2025 at 9:54 AM, Physician #1 stated, I don't remember if they notified me about [Resident #30's name] weight loss. The registered dietitian is able to put in her own hers into the system if she has any recommendations. 2) Review of Resident #66's weights on 08/01/2025, the resident weighed 171 lbs [pounds]. On 11/04/2025, the resident weighed 156 lbs which is a -8.77% Loss.Review of Resident #66's weights on 5/3/2025, the resident weighed 174 lbs. On 11/04/2025, the resident weighed 156 lbs which is a -10.34% Loss.Review of Resident #66 progress note did not reveal any dietary notes.During an interview on 12/3/2025 at 1:12 PM, the Registered Dietician stated, There aren't any progress notes in the system. Last nutritional comprehensive was done in August 2023. We have a list of high-risk patients to see. Usually, I will review weights to see who has had significant weight loss and they will be included in my list to see them. I am not sure how we missed that. She [Resident #66] is not on my list. She should have been seen on November (2025) and October (2025). I am not sure why this happened.During an interview on 12/3/2025 at 2:43 PM, the Registered Dietician (RD)stated, I reviewed her record and she is trending down. Currently, resident is on palliative care due to Cancer, COPD [Chronic Obstructive Pulmonary Disease], and CKD [Chronic Kidney Disease]. She has had past weight fluctuations. He BMI Body mass index] is with in normal limits.During an interview on 12/3/2025 at 3:15 PM, the Director of Nursing stated, Registered Dietitian has a tracking log, and she has access to PCC [point click care]. We do not tell them who to see normally. We have clinical meetings were we will review weight loss and nine out of ten she always has them on her list to see them. She [Resident #66] fell through the cracks, she should have been seen by the RD. [Resident #66's name] was reweighed and gain weight almost makes me feel like the November [2025] weight was incorrect. A nutritional assessment should be done Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105333 If continuation sheet Page 6 of 26 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 105333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at MT Dora, Inc 3050 Brown Ave Mount Dora, FL 32757 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete quarterly or when a significant change occurs. My regional nurse is getting more clarification.During an interview on 12/4/2025 at 12:42 PM, Physician Assistant #1 stated, I want to say yes, the facility notified me of her [Resident #66] weight loss. Her boyfriend was telling her she was overweight. I believe I spoke to the unit manager, and we had a discussion about protein drinks. I believe that the registered dietitian can put her own orders in if she feels that the resident needs anything she will go ahead and communicate to tell me, but she can put in her orders.During an interview on 12/3/2025 at 1:43 PM, Certified Dietary Manager stated, [Resident #66's name] is a vegetarian per se [latin for ‘in itself'] she eats dairy, chicken and seafood. No beef or pork products. She eats quite well and submits special orders often. The RD has not communicated any weight loss to me regarding [Resident #66's name]. The RD is the only one looking at weights. I look at the ideal body weight and BMI and recommendations made.Review of the facility policy and procedure titled Nutritional Management with a last review date of 1/28/2025 read, Policy: The facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition. Compliance Guidelines: C. Comprehensive nutritional assessment will be completed by a dietitian within 72 hours of admission, annually, and upon significant change in condition. Follow up assessments will be completed as needed. Event ID: Facility ID: 105333 If continuation sheet Page 7 of 26 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 105333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at MT Dora, Inc 3050 Brown Ave Mount Dora, FL 32757 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 oxygen was administered at the correct flow rate for 1 (Resident #88) of 3 residents and failed to change the nebulizer treatment bag 1 (Resident #50) of 3 reviewed for respiratory services.Findings include: Residents Affected - Few 1) During an observation on 12/01/2025 at 9:34 AM, Resident #88 was lying in bed with oxygen being administered at 4 liters of oxygen per minute via nasal cannula. [photographic evidence obtained] During an observation on 12/02/2025 at 8:22 AM, Resident #88 was sitting up in bed eating breakfast. Oxygen was being administered via nasal cannula at 4 liters per minute. Review of Resident #88's physician order dated 6/28/2025 read, Oxygen continuous at 3 lpn [sic] liters/ min [liters per minute] via nasal cannula medical DX [diagnosis]: CHF [congestive heart failure] every shift for CHF. During an observation on 12/3/2025 at 10:10 AM, Staff G, Licensed Practical Nurse (LPN) entered Resident #88's room. Resident #88 was lying in bed with oxygen being administered via nasal cannula at 4 liters per minute. During an interview on 12/3/2025 at 10:11 AM, Staff G, LPN, stated, [Resident #88's name] oxygen was running at 4 liters per minute, and she has orders for 3 liters per minute I will have to readjust her oxygen. During an interview on 12/3/2025 at 10:24 AM, the Director of Nursing stated, Nursing staff should check the oxygen flow rate for accuracy every shift. We have some residents that will adjust the oxygen themselves. [Resident #88's name] is not one of them. Review of the facility policy and procedure titled, Tracheostomy Care and Suctioning/Oxygen with a last review date of 1/28/2025 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 standard s of practice, the comprehensive person-center 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 physician, treatments, mechanical ventilation, tracheostomy care and /or suctioning. 2) Review of Resident #50's admission record documented she was admitted to the facility on [DATE] with medical diagnoses that included Parkinson's disease without dyskinesia, without mention of fluctuations; type 2 diabetes mellitus with diabetic neuropathy, unspecified; type 2 diabetes mellitus with hyperglycemia; interstitial pulmonary disease, unspecified; unspecified asthma, unspecified; paroxysmal atrial fibrillation; and essential (primary) hypertension. During an observation on 12/01/2025 at 11:05 AM, Resident #50's nebulizer supply bag, containing the tubing and the face mask was dated 11/22/25. (photographic evidence)During an interview on 12/01/2025 at 11:15 AM, Resident #50 stated that her nebulizer treatments were as needed because she had a history of bronchitis and asthma. During an observation on 12/03/2025 at approximately 9:30 AM, Resident #50's supply bag for her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105333 If continuation sheet Page 8 of 26 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 105333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at MT Dora, Inc 3050 Brown Ave Mount Dora, FL 32757 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 nebulizer, that contained the tubing and the face mask was dated 11/22/2025. (photographic evidence) Level of Harm - Minimal harm or potential for actual harm Review of Resident #50's physician orders revealed an order dated 10/25/2025 that read, Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/ML (milligrams per milliliter) (Ipratropium-Albuterol): 3 ml inhale orally every 6 hours as needed for wheezing/cough. Residents Affected - Few Review of Resident #50's MAR (Medication Administration Record) for November 2025 read, Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/ML (milligrams per milliliter) (Ipratropium-Albuterol): 3 ml inhale orally every 6 hours as needed for wheezing/cough There was documentation of administration on 11/23/2025. During an interview on 12/03/2025 at 9:49 AM, the DON (Director of Nursing) stated that the expectation was that oxygen, nebulizer and other respiratory equipment was supposed to have the tubing and masks changed every week. The supplies were to be kept in the plastic bag when not in use, and the tubing and bag were supposed to have the date when they were changed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105333 If continuation sheet Page 9 of 26 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 105333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at MT Dora, Inc 3050 Brown Ave Mount Dora, FL 32757 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure the physician provided a documented rationale for no action taken following the pharmacist's recommendation for 2 residents, Resident #10 and Resident #50, of 5 residents sampled for unnecessary medications.Findings include:1) Review of Resident #10's pharmacy consultation reports dated 3/18/2025, 4/28/2025 and 5/28/2025 revealed the pharmacist noted Resident #10's prescribed as needed medication, Midodrine, had not been used within the previous 60 days and recommended, Please consider discontinuing due to lack of use. Review of Resident #10's physician progress note dated 3/28/2025 revealed the Advanced Registered Nurse Practitioner had documented, Continue Midodrine but failed to document the rationale for no action taken following the pharmacist's recommendation to discontinue use of the medication. Review of Resident #10's physician orders showed an active physician order dated 10/31/2024 that read, Midodrine HCl [hydrochloride] oral tablet 5 mg [milligrams], Give 1 tablet by mouth every 8 hours as needed for SBP [systolic blood pressure] < [less than] 100. During interview on 12/3/2025 at 12:27 PM, the Director of Nursing confirmed there was no record to show the physician provided a documented rationale for no action taken following the pharmacist's recommendation. 2) Review of Resident #50's admission record documented she was admitted to the facility on [DATE] with medical diagnoses that included Parkinson's disease without dyskinesia, without mention of fluctuations; type 2 diabetes mellitus with diabetic neuropathy, unspecified; type 2 diabetes mellitus with hyperglycemia; interstitial pulmonary disease, unspecified; unspecified asthma, unspecified; long term (current) use of anticoagulants; paroxysmal atrial fibrillation; and essential (primary) hypertension. Review of the Consultation Report with the Pharmacist recommendations dated 7/30/2025 read, Comment: Issued on 7/30/2025. Clinical Priority Recommendation: Prompt Response Requested. [Resident #50's Name] receives Eliquis (apixaban) [anticoagulant (blood thinner) medication used to prevent and treat blood clots] 5 mg BID [twice daily]. Recommendation: Please decrease to Eliquis 2.5 mg twice daily. There was a hand-written note that read, Disagree, it was not signed or dated. Review of Resident #50's progress notes from 7/01/2025 through 12/01/2025 revealed no mention of Eliquis or declination of pharmacy recommendation. Review of Resident #50's Medication Administration Record (MAR) for July 2025 and August 2025 revealed an entry that read, Apixaban Oral Tablet 5 MG (Apixaban): Give 1 tablet by mouth two times a day related to Paroxysmal Atrial Fibrillation [an irregular heartbeat that starts and stops on its own, with episodes lasting less than a week and often resolving within 24 hours]. There was documentation of administration twice daily from 7/01/2025 through 8/31/2025. A Consultation Report for Resident #50 with Pharmacist's recommendation dated 10/27/2025 read, Comment: [Resident #50's Name] receives lidocaine patch [a medicated, adhesive transdermal (method of administering a medication or drug through the skin) patch that delivers the local anesthetic lidocaine through the skin to provide localized pain relief]. Recommendation: Please ensure that the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105333 If continuation sheet Page 10 of 26 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 105333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at MT Dora, Inc 3050 Brown Ave Mount Dora, FL 32757 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few following administration recommendations are followed: Order should include instructions to remove after 12 hours. The Director of Nursing Comments documented the signature of the DON; it was dated 10/29/2025. Review of Resident #50's Physician's Orders revealed an order dated 10/25/2024 that read, Lidocaine External Patch 5% (Lidocaine): Apply to affected area topically one time a day for pain. Review of Resident #50's MAR for October 2025 revealed an entry that read, Lidocaine External Patch 5% (Lidocaine): Apply to affected area topically one time a day for pain. Review of Resident #50's MAR for November 2025 revealed an entry that read, Lidocaine External Patch 5% (Lidocaine): Apply to affected area topically one time a day for pain. Review of Resident #50's physician progress note, dated 10/31/2025, from the PA #1 (Physician's Assistant from the Primary Care Physician's group for Resident #50). It read, . Meds [medications] were reviewed . There was no mention of her Lidocaine patch or altering the order to include instructions for removal after 12 hours. During an interview on 12/03/2025 at approximately 3:00 PM, the DON (Director of Nursing) stated that she had reviewed Resident #50's medical record pertaining the pharmacist recommendations and did not find any progress notes or other documentation addressing the reasons the pharmacist's recommendations had not been followed. During an interview on 12/04/2025 at 12:48 PM, PA #1 stated that he was aware of the process regarding the pharmacy recommendations, and that they were supposed to mark agree or disagree and that there was a section to write in the reason for disagreeing with a recommendation. He did not recall a conversation at the end of October [2025] with the DON regarding a removal order for Resident #50's Lidocaine patch. Review of the policy and procedure titled, Medication Regimen Review, with the last review date of 1/28/2025, read, 9. Facility should encourage physician/prescriber or other responsible parties receiving the MRR [Medication Regimen Review] and the director of nursing to act upon the recommendations contained in the MRR. 9.1 For those issues that require physician/prescriber intervention, facility should encourage physician/prescriber to either accept and act upon the recommendation contained in the MRR and provide explanations as to why the recommendation was rejected, as outlined in the State Operations Manual Appendix PP. 9.2 The attending physician should document in the residents' health record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. 9.2.1 If the attending physician/prescriber has decided to make no change in the medication, the attending physician should document the rationale in the resident's health record. Review of the policy and procedure titled, Physician Services, with an issued date of 3/29/2025, with last revision date of 1/28/2025, read, Policy: It is the policy of the facility to provide Physician Services in accordance to State and Federal regulations. Procedure: . 8. All physician orders will be followed as prescribed and if not followed, the reason shall be recorded on the residents medical record during that shift. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105333 If continuation sheet Page 11 of 26 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 105333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at MT Dora, Inc 3050 Brown Ave Mount Dora, FL 32757 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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 that residents' medication regimens were free from unnecessary medications, including excessive doses/dosages for 3 (Resident #50, Resident #22 and Resident #71) of 5 residents reviewed for unnecessary medications.Findings include:1) Review of Resident #22's admission data revealed that she was admitted to the facility on [DATE] with medical diagnosis that include Alzheimer's Disease with late onset, acute chronic combined systolic heart failure, difficulty walking, major depressive disorder, anemia, essential (primary) hypertension, paroxysmal atrial fibrillation, cardiomegaly, unspecified dementia, type 2 diabetes mellitus and anxiety disorder (not an inclusive list). Residents Affected - Few Review of Resident #22's physician orders revealed an order dated 10/29/2025 read, DIL-XR Oral Capsule Extended Release 24 hours 120 milligrams (mg), give 2 capsules by mouth one time a day for hypertension, hold for systolic blood pressure (SBP) below 160. Review of Resident #22's physician orders revealed an order dated 10/29/2025 read, Metoprolol Succinate ER Oral Tablet Extended Release 24 hours, 25 MG, give 3 tablets by mouth one time a day for hypertension, total 75 mg, hold for SBP below 160. Review of Resident #22's Medication Administration Record (MAR) for November 2025 revealed DIL-XR Oral Capsule was administered on 11/10/2025 at 10:00 AM for a blood pressure of 131/74. Review of Resident #22's MAR for November 2025 revealed DIL-XR Oral Capsule was administered on 11/14/2025 at 10:00 AM for a blood pressure of 123/83. Review of Resident #22's MAR for November 2025 revealed DIL-XR Oral Capsule was administered on 11/17/2025 at 10:00 AM for a blood pressure of 129/80. Review of Resident #22's MAR for November 2025 revealed DIL-XR Oral Capsule was administered on 11/24/2025 at 10:00 AM for a blood pressure of 131/65. Review of Resident #22's MAR for November 2025 revealed DIL-XR Oral Capsule was administered on 11/28/2025 at 10:00 AM for a blood pressure of 131/76. Review of Resident #22's MAR for November 2025 revealed Metoprolol ER oral tablet was administered on 11/24/2025 at 8:00 AM for a blood pressure of 123/68. 2) Review of Resident #71's admission data revealed that she was admitted to the facility on [DATE] with medical diagnosis that include heart failure, muscle weakness, malignant neoplasm of the cecum, hypotension, anemia, chronic kidney disease, anxiety disorder, major depressive disorder and essential hypertension (not an inclusive list). Review of Resident #71's physician orders revealed an order dated 8/21/2023 read, Lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, give 1 tablet by mouth one time a day for hypertension, hold is SBP is less than 110. Review of Resident #71's physician orders revealed an order dated 11/7/2023 read, Midodrine oral tablet 5 mg, give 1 tablet by mouth one time a day for hypotension, give if BP (blood pressure) is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105333 If continuation sheet Page 12 of 26 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 105333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at MT Dora, Inc 3050 Brown Ave Mount Dora, FL 32757 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 0757 below 100/60. Level of Harm - Minimal harm or potential for actual harm Review of Resident #71's MAR for November 2025 revealed Lisinopril-hydrochlorothiazide oral tablet was administered on 11/10/2025 at 9:00 AM for a blood pressure of 103/62. Residents Affected - Few Review of Resident #71's MAR for November 2025 revealed Midodrine oral tablet was administered on 11/11/2025 at 9:00 AM for a blood pressure of 105/58. Review of Resident #71's MAR for November 2025 revealed Midodrine oral tablet was administered on 11/25/2025 at 9:00 AM for a blood pressure of 109/59. During an interview on 12/2/2025 at 4:40 PM, Staff B stated that she misinterpreted the order and did administer the medications on those dates. During an interview on 12/3/2025 at 3:35 PM, the DON (Director of Nursing) stated that her expectations would be that the physician orders would be read complete, administered as order and if there were any concerns with clarification of the order the nurse would contact the physician or her. 3) Review of Resident #50's admission record documented she was admitted to the facility on [DATE] with medical diagnoses that included Parkinson's disease without dyskinesia, without mention of fluctuations; type 2 diabetes mellitus with diabetic neuropathy, unspecified; type 2 diabetes mellitus with hyperglycemia; interstitial pulmonary disease, unspecified; unspecified asthma, unspecified; long term (current) use of anticoagulants; paroxysmal atrial fibrillation; and essential (primary) hypertension. The Pharmacist recommendation dated 1/21/2025 read, Please reduce Methocarbamol to 750 mg QD with the end goal of discontinuation. It was accepted and signed by Resident #50's primary care physician. Review of Resident #50's physician orders revealed an order dated 11/30/2024 that read, Methocarbamol Oral Tablet 750 MG (milligrams) (Methocarbamol): Give 1 tablet by mouth two times a day for muscle spasms. Review of Resident #50's physician orders revealed an order dated 10/25/2025 that read, Methocarbamol Oral Tablet 750 MG (milligrams) (Methocarbamol): Give 1 tablet by mouth two times a day for muscle spasms. Review of Resident #50's MAR (Medication Administration Record) for January 2025 revealed an entry that read, Methocarbamol Oral Tablet 750 MG (milligrams) (Methocarbamol): Give 1 tablet by mouth two times a day for muscle spasms. There was documentation of administration twice daily from 1/01/2025 through 1/31/2025. Review of Resident #50's MAR for February 2025 revealed an entry that read, Methocarbamol Oral Tablet 750 MG (milligrams) (Methocarbamol): Give 1 tablet by mouth two times a day for muscle spasms. There was documentation of administration twice daily from 2/01/2025 through 2/28/2025. Review of Resident #50's MAR for November 2025 revealed an entry that read, Methocarbamol Oral Tablet 750 MG (milligrams) (Methocarbamol): Give 1 tablet by mouth two times a day for muscle spasms. There was documentation of administration twice daily for 55 out of 60 scheduled doses from 11/01/2025 through 11/30/2025. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105333 If continuation sheet Page 13 of 26 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 105333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at MT Dora, Inc 3050 Brown Ave Mount Dora, FL 32757 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 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 12/02/2025 at 5:00 PM, the DON (Director of Nursing) stated that she was aware that they had problems with getting the changes and orders from the pharmacist recommendations entered and carried out. During an interview on 12/03/2025 at 3:00 PM, the DON stated that she had reviewed Resident #50's medical record pertaining the pharmacist recommendations and did not find any progress notes or other documentation addressing the reasons the recommendations had not been followed. Review of the Policy and Procedure titled Physician Services, with an issued date of 3/29/2025 and last revision date of 1/28/2025, read, Policy: It is the policy of the facility to provide Physician Services in accordance to State and Federal regulations. Procedure: . 8. All physician orders will be followed as prescribed and if not followed, the reason shall be recorded on the residence medical record during that shift. Review of the Policy and Procedure titled General Dose Preparation and Medication Administration, with an effective date 12/01/2007 and last revision date of 1/28/2025, read, Applicability: This 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105333 If continuation sheet Page 14 of 26 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 105333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at MT Dora, Inc 3050 Brown Ave Mount Dora, FL 32757 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 - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medical records were complete and accurate for 1 (Resident #29) of 1 resident reviewed for activities of daily living, 3 (Residents #36, #70, and #88) of 5 residents review for skin conditions and 5 (Resident #2, #3, #51, #70 and #105) of 10 residents reviewed for medication management.Findings include: 1) Review of Resident #29's care plan initiated on 7/10/2025 read, [Resident #29's name] is facing a significant shortfall in her self-care performance related to Activities of daily living (ADL), which is associated with the consequences of a terminal diagnosis in its end stage. Interventions: Dependent in toileting/always incontinent. Review of Resident #29's Functional Goals and Abilities Evaluation dated 9/29/2025 documented the resident was dependent on helper (staff) for toileting hygiene. Review of Resident #29's bladder continence documentation for the month of November 2025 revealed blank entries on day shift on 11/4/2025, 11/18/2025, 11/24/2025, and 11/25/2025. Evening shift revealed blank entries on 11/6/2025, and 11/16/2025, and night shift on 11/14/2025. Review of Resident #29's bowel continence documentation for the month of November 2025 revealed blank entries on day shift for 11/4/2025, 11/16/2025, 11/24/2025, and 11/25/2025, On evening shift for 11/6/2025, 11/12/2025, and 11/16/2025 and on night shift blank entries for 11/14/2025. During an interview on 12/4/2025 at 12:30 PM, the Director of Nursing stated, I have no other supporting documentation regarding care provided to [Resident #29's name]. I expect the staff to fill out accurately the task when providing care. 2) During an observation on 12/01/2025 at 9:34 AM, Resident #88 was lying in bed. Resident #88 right lower leg has a dressing dated 11/27/2025 [Staff F initials]. Review of Resident #88's physician order dated 11/20/2025 read, Wound Care: Right Heel-Skin prep, cover with ABD [abdominal] pad and wrap with kerlix. Secure with tape, every day shift for unstageable pressure injury and as needed for soiled/displaced/wound rounds. Review of Resident #88's Treatment Administration Record (TAR) for the month of November 2025 for wound care to the right heel documented wound care was completed on 11/28/2025, 11/29/2025 and 11/30/2025. During an interview on 12/3/2025 at 10:16 AM, Staff G, Licensed Practical Nurse (LPN), stated, I do not really recall. I remember doing something on Saturday [11/29/2025] with [Resident #88's name] right lower leg. I just cannot remember. If there is a check in the system it means it was completed. On Saturday [11/29/2025] that nurse who came in to do wound care had to take a cart and the nurses were helping to do the wound care. During an interview on 12/3/2025 at 12:56 PM, the Director of Nursing stated, Wound care should be documented accurately. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105333 If continuation sheet Page 15 of 26 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 105333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at MT Dora, Inc 3050 Brown Ave Mount Dora, FL 32757 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 - Some 3) During an observation on12/01/2025 at 10:07 AM, Resident #36 was lying in bed right foot dressing dated 11/27 [Staff F initials]. Review of Resident #36's physician order dated 11/20/2025 read, Wound Care: Right heel-cleanse with Dakin's 1/2 str. Sol [strength solution] pat dry. Skin prep peri wound. Apply calcium alginate, cover with ABD pad, wrap with rolled gauze secure with tape, every day shift for unstageable pressure ulcer. Review of Resident #36's TAR for the month of November 2025 for right heel wound care documented on 11/29/2025 code 9 [see progress notes] and on 11/30/2025 signed off as completed. Review of Resident #36's progress noted dated 11/29/2025 read, done by wound nurse. Review of Resident #36's physician order dated 10/17/2025 read, Wound care: Right lateral foot-skin prep, offload every day shift for arterial ulcer. Review of Resident #36 TAR for the month of November 2025 for right lateral foot skin prep documented treatment completed on 11/28/2025, 11/29/2025 and 11/30/2025. Review of Resident #36's physician order dated 10/31/2025 read, Wound Care: Right 2nd toe-cleanse with betadine, pat dry. Skin prep peri wound. Apply betadine -soaked gauze then wrap with rolled gauze and secure with tape, every day shift for DM Ulcer. Review of Resident #36 TAR for the month of November 2025 for Right 2nd toe cleanse with betadine documented blank entries on 11/7/2025, 11/11/2025, 11/12/2025, 11/14/2025, and 11/18/2025. Review of Resident #36's physician order dated 11/20/2025 read, Wound Care: Right 2nd toe-cleanse with Dakin's 1/2 str. Sol, pat dry. Skin prep peri wound, Apply calcium alginate cover with ABD pad, wrap with rolled gauze, secure with tape, every day shift for DM Ulcer. Review of Resident #36's TAR for the month of November 2025 for Right second toe wound care documented on 11/29/2025 code 9 [see progress notes] and on 11/30/2025 signed off as completed. Review of Resident #36's physician order dated 10/31/2025, read, Wound Care: Right Lateral great toe Cleanse with betadine , pat dry skin prep peri wound. Apply betadine soaked gauze then wrap with rolled gauze and secure with tape ever day shift for arterial ulcer. Review of Resident #36's TAR for the month of November 2025 for Right Lateral great toe documented blank entries on 11/7/2025, 11/11/2025, 11/12/2025, and 11/18/2025. Review of Resident #36's physician order dated 11/20/2025, read, Wound Care: Right lateral great toe cleanse with Dakins 1/2 str. Sol pat dry. Skin prep peri wound. Apply calcium alginate cover with ABD pad, wrap with rolled gauze, secure tape, every day shift for arterial ulcer. Review of Resident #36's TAR for the month of November 2025 for Right lateral great toe cleanse with Dakins wound care documented on 11/29/2025 code 9 [see progress notes] and on 11/30/2025 signed off as completed. Review of Resident #36's physician order dated 11/20/2025 read, Wound Care: Right Lateral (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105333 If continuation sheet Page 16 of 26 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 105333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at MT Dora, Inc 3050 Brown Ave Mount Dora, FL 32757 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 heel-cleanse with Dakin's 1/2 str. Sol, pat dry skin prep peri wound. Apply calcium alginate cover with ABD pad, wrap with rolled gauze, secure with tape, every day shift for arterial ulcer. Review of Resident #36's TAR for the month of November 2025 for Right lateral heel wound care documented on 11/29/2025 code 9 [see progress notes] and on 11/30/2025 signed off as completed. Residents Affected - Some Review of Resident #36's physician order dated 10/31/2025, read, Wound Care: Right lateral second toe-cleanse with betadine, apply calcium alginate, cover with ABD pad, wrap with rolled gauze, secure with tape, every day shift for arterial ulcer. Review of Resident #36's TAR for the month of November 2025 for Right Lateral second toe documented blank entries on 11/7/2025, 11/11/2025 and on 11/12/2025. Review of Resident #36's physician order dated 11/13/2025 read, Wound Care: Right Lateral second toe, cleanse with betadine , protect peri wound with skin prep, apply wet to dry betadine-soaked gauze, cover with ABD pad, wrap with rolled gauze, secure with tape, every day shift for arterial ulcer. Review of Resident #36's TAR for the month of November 2025 for Right Lateral second toe documented a blank entry on 11/18/2025. Review of Resident #36's physician order dated 11/20/2025 read, Wound Care: Right lateral second toe-cleanse with Dakin's 1/2 str. Sol pat dry skin prep peri wound. Apply calcium alginate, cover with ABD pad, wrap with rolled gauze, secure with tape, every day shift for arterial ulcer. Review of Resident #36's TAR for the month of November 2025 for right lateral second toe, cleanse with Dakins wound care documented on 11/29/2025 code 9 [see progress notes] and on 11/30/2025 signed off as completed. During interview on 12/3/2025 at 10:16 AM, Staff G, LPN, stated, I might check off the wound care and sometimes you might forget. I am wondering if it was supposed to get done by the wound care nurse, so I checked it off and it didn't get done. During an interview on 12/4/2025 at 8:07 AM, Staff F, Wound Care Nurse, LPN, stated, On Friday I am not on the cart that is my documentation day. On 11/11/2025, I was training and was not on the wound care cart. I am not able to say what happened on 11/12/2025 or 11/18/2025. I know I had training two days, but I have no notes for those two days. I always do her wound care if I am here. I don't know why those days have blanks. Review of the facility policy and procedure titled, Documentation with a last review date of 1/28/2025, read, Policy: Each resident medical record shall contain an accurate representation of the actual experience of the resident and include enough information to provide a picture of the residents progress through complete, accurate, and timely documentation. Review of the facility policy and procedure titled, Clean Dressing Change with a last review date of 1/28/2025 read, 26. Document the completion of dressing change on the treatment record. 4) Review of Resident #2's physician order dated 10/6/2025 read, Lantus Subcutaneous Solution 100 Unit/ML [Unit per milliliter] (Insulin Glargine) Inject 10 unit subcutaneously one time a day for Hyperglycemia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105333 If continuation sheet Page 17 of 26 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 105333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at MT Dora, Inc 3050 Brown Ave Mount Dora, FL 32757 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 Review of Resident #2's physician order dated 11/4/2025 read, Lantus Subcutaneous Solution 100 Unit/ML (Insulin Glargine) Inject 12 unit subcutaneously one time a day for Hyperglycemia. Review of Resident #2's Medication Administration Record for the month of November 2025 for Lantus 100 Unit/ML inject 10 units documented on 11/2/2025 at bedtime coded 13 [Glucose out of Parameters]. Residents Affected - Some Review of Resident #2's Medication Administration Record for the month of November 2025 for Lantus 100 Unit/ML inject 12 units documented at bedtime code 13 on 11/15/2025, 11/16/2025, 11/22/2025, and 11/24/2025. During an interview on 12/3/2025 at 11:59 AM Physician Assistant #1 stated, I have not gotten phone calls regarding staff holding [Resident #2's name] insulin. Communication and reporting is a big deal here. I have parameters in place for a reason. I want to be notified. I don't need a phone call every time but until we have trust and a pattern I want the staff to call me, but a lot of times they do not. [Resident #2's name] has not run into any danger, it is not a big issue. During an interview on 12/3/2025 at 12:57 PM, the Director of Nursing stated, I expect nurses to use their nursing judgment but always communicate with the provider and follow physician orders. If they are using their nursing judgment they should call the provider and get clarification. Review of the facility policy and procedure titled Physician Services with a last review date of 1/28/2025 read, 8. All physician orders will be followed as prescribed and if not followed, the reason shall be recorded on the resident's medical record during that shift. 5) Review of Resident #3's physician order dated 9/28/2025, read, Insulin Lispro Prot & Lispro Subcutaneous Suspension (75-25) 100 Unit/ML (Insulin Lispro Protamine & Lispro) Inject 16 units subcutaneously two times a day for Hyperglycemia (Before breakfast and bedtime). Review of Resident #3's physician order dated 11/30/2025, read, Insulin Lispro Prot & Lispro Subcutaneous Suspension (75-25) 100 UNIT/ML (Insulin Lispro Protamine & Lispro) Inject 16 units subcutaneously one time a day for DM [Diabetes Mellitus]. Review of Resident #3's physician order dated 11/2/2025, read, Hold insulin if blood sugar is less than 90 every shift. Review of Resident #3's Medication Administration Record for the month of November 2025 for Insulin Lispro Protamine and Lispro documented at 2100 [9:00 PM] on 11/1/2025 blood sugar level 114 coded 13, on 11/16/2025 blood sugar level 112 coded 13, and on 11/22/2025 blood sugar level 138 coded 13 [Glucose out of Parameters]. During an interview on 12/3/2025 at 4:53 PM, Physician #1 stated, I don't recall notification from staff regarding [Resident #3's name]. Resident #3 has not had any medical emergencies regarding her diabetic management. 6) Review of Resident #105's admission data revealed that she was admitted to the facility on [DATE] with idiopathic peripheral autonomic neuropathy, type 2 diabetes mellitus with diabetic neuropathy, heart failure, major depressive disorder, chronic pain, essential hypertension, morbid obesity and nicotine dependence (not an inclusive list). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105333 If continuation sheet Page 18 of 26 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 105333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at MT Dora, Inc 3050 Brown Ave Mount Dora, FL 32757 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 - Some Review of Resident #105's physician order dated 11/5/2025 read, Lantus SoloStar Subcutaneous Solution Pen-injector, 100 units/ ML (milliliters), inject 30 units subcutaneously one time a day for DM (diabetes mellitus). Review of Resident #105's November 2025's Medication Administration Record(MAR) revealed that there was nothing documented on the following days: 11/11/2025, 11/17/2025 and 11/18/2025 for Lantus Solostar Subcutaneous Solution Pen-injector. During an interview on 12/4/2025 at 8:45 AM, the DON stated that she reviewed Resident #105's November 2025 MAR for Lantus Solostar Subcutaneous Solution Pen-injector documentation for 11/11/2025, 11/17/2025 and 11/18/2025 and spoke to the nurses who were assigned to the resident on those days and stated that [Resident #105's Name] will be out on the smoking patio during the administration time and will not come in for administration of the medication. DON stated that her expectations should be that the nurse attempting to administer the medication should document as resident refusal instead of leaving it blank. 7) Review of Resident #51's admission Record documented an admission to the facility dated 5/26/2023 with medical diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side; type 2 diabetes mellitus (DM) with diabetic polyneuropathy; and essential (primary) hypertension. Review of Resident #51's most recent Minimum Data Set comprehensive assessment documented the resident had a BIMS (brief interview for mental status) of 15/15, indicating intact cognition. Review of Resident #51's physician orders dated 10/16/2025 read, Insulin Glargine Subcutaneous Solution Pen-injector 100 units/ML (Insulin Glargine): Inject 30 unit subcutaneously one time a day for DM 2 (type 2 diabetes mellitus). Review of Resident #51's physician orders dated 03/05/2025 read, Insulin Glargine Subcutaneous Solution Pen-injector 100 units/ML (Insulin Glargine): Inject 5 unit subcutaneously at bedtime for DM 2 (type 2 diabetes mellitus). This order was discontinued on 10/16/2025. Review of Resident #51's physician orders dated 05/26/2025 read, Humulin N Subcutaneous Suspension 100 unit/ML (Insulin NPH (Human) (Isophane)): Inject 18 unit subcutaneously two times a day for Type II DM. Hold for BG (blood glucose) <70. This order was discontinued on 10/16/2025. Review of Resident #51's physician orders dated 7/17/2023 read, Humalog Subcutaneous Solution Cartridge 100 unit/ML (Insulin Lispro): Inject subcutaneously before meals and at bedtime for Type II DM Below 60 or above 400 call MD. Review of Resident #51's MAR (Medication Administration Record) for the month of September 2025 read, Humalog Subcutaneous Solution Cartridge 100 unit/ML (Insulin Lispro): Inject as per sliding scale: if 150 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; > 400 call MD, subcutaneously before meals and at bedtime for Type II DM Below 60 or above 400 call MD. There was no documentation on 9/07/2025 at 6:30 AM; 9/12/2025 at 6:30 AM; 9/19/2025 at 4:30 PM; 9/20/2025 at 6:30 AM; and 9/21/2025 at 6:30 AM. Review of Resident #51's Progress Notes, including eMAR (electronic Medication Administration Record) notes for 9/01/2025 through 9/30/2025 revealed there were no notes regarding Resident #51's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105333 If continuation sheet Page 19 of 26 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 105333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at MT Dora, Inc 3050 Brown Ave Mount Dora, FL 32757 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 insulin. Level of Harm - Minimal harm or potential for actual harm Review of Resident #51's MAR for the month of October 2025, read, Insulin Glargine Subcutaneous Solution Pen-injector 100 units/ML (Insulin Glargine): Inject 30 unit subcutaneously one time a day for DM 2. There was documentation on 10/18/2025 and 10/19/2025 that read code 9 &ndash; other/see nurse notes. Residents Affected - Some Review of Resident #51's progress notes for 10/18/2025 and 10/19/2025 revealed an eMAR Medication Administration Note dated 10/19/2025 at 12:05 AM that read, Insulin Glargine Subcutaneous Solution Pen-injector 100 units/ML (Insulin Glargine): Inject 30 unit subcutaneously one time a day for DM 2. Refused. There was no documentation of physician or provider notification. There were no progress notes for 10/18/2025 related to insulin or blood glucose. Review of Resident #51's MAR for the month of October 2025, read, Humalog Subcutaneous Solution Cartridge 100 unit/ML (Insulin Lispro): Inject as per sliding scale: if 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; > 400 call MD, subcutaneously before meals and at bedtime for Type II DM Below 60 or above 400 call MD. There was documentation as follows: On 10/18/2025 at 10:00PM, 10/19/2025 and 10/202025 at 6:30 AM &ndash; NA (not applicable) for the blood sugar reading, and 9 (Other/See Nurse Notes) for the dosage of insulin administered; on 10/21/2025 at 4:30 PM, there was nothing documented for a blood sugar reading or dosage of insulin administered; and on 10/28/2025 at 11:30 AM &ndash; NA was documented for a blood sugar reading, and no dosage was documented for the amount of insulin administered. Review of Resident #51's progress notes, including eMAR (electronic Medication Administration Record) notes for 10/01/2025 through 10/31/2025 revealed no notes regarding provider notification for Resident #51's Humalog insulin and corresponding blood sugar monitoring. Review of Resident #51's MAR for the month of November read, Insulin Glargine Subcutaneous Solution Pen-injector 100 units/ML (Insulin Glargine): Inject 30 unit subcutaneously one time a day for DM 2. Code 9 (other/see nurse notes) was documented on 11/19/2025, 11/24/2025, 11/25/2025, 11/27/2025, 11/29/2025, and 11/30/2025. Review of Resident #51's progress notes, including eMAR (electronic Medication Administration Record) notes for 11/01/2025 through 11/30/2025 revealed there were no notes regarding provider notification for Resident #51's Insulin Glargine. Review of Resident #51's MAR for November 2025 read, Humalog Subcutaneous Solution Cartridge 100 unit/ML (Insulin Lispro): Inject as per sliding scale: if 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; > 400 call MD, subcutaneously before meals and at bedtime for Type II DM Below 60 or above 400 call MD. On 11/02/2025, 11/15/2025, 11/16/2025, 11/17/2025, 11/26/2025, and 11/28/2025 at 6:30 AM; 11/16/2025, 11/19/2025, 11/24/2025, 11/25/2025, 11/27/2025, 11/29/2025, and 11/30/2025 at 10:00 PM &ndash; NA was documented for the blood sugar reading, and 9 for the dosage of insulin administered. On 11/25/2025 at 6:30 AM &ndash; there was nothing documented for the blood sugar reading or the dosage of insulin administered. On 11/14/2025 and 11/18/2025 at 4:30 PM, and 11/18/2025 at 11:30 AM &ndash; NA for the blood sugar reading, and no dosage for the amount of insulin administered. Review of Resident #51's progress notes, including eMAR (electronic Medication Administration Record) notes for 11/01/2025 through 11/30/2025 revealed no notes regarding provider notification for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105333 If continuation sheet Page 20 of 26 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 105333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at MT Dora, Inc 3050 Brown Ave Mount Dora, FL 32757 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 Resident #51's Humalog insulin and corresponding blood sugar monitoring. Level of Harm - Minimal harm or potential for actual harm Review of Resident #51's MAR from 11/01/2025 through 12/03/2025, read, Humalog Subcutaneous Solution Cartridge 100 unit/ML (Insulin Lispro): Inject as per sliding scale: if 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; > 400 call MD, subcutaneously before meals and at bedtime for Type II DM Below 60 or above 400 call MD. On 12/01/2025 at 6:30 AM NA was documented for the blood sugar reading, and 9 for the dosage of insulin administered. Residents Affected - Some Review of Resident #51's progress notes, including eMAR (electronic Medication Administration Record) notes for 11/01/2025 through 12/03/2025 revealed no notes regarding provider notification for Resident #51's Insulin Glargine. During an interview on 12/03/2025 at 10:15 AM, Resident #51 stated that he did not refuse his accu checks (blood glucose monitoring test) or his insulin injections even late at night or early in the morning. During an interview on 12/03/2025 at 3:55 PM, the DON stated that the expectation was for the nurses to notify the provider if a resident refused their medications or treatments. During an interview on 12/03/2025 at 4:44 PM, Physician #1 stated, I receive so many calls from so many facilities. I may have received 1 or 2 calls [regarding Resident #51]. I tell them to just put in your notes that he refused and re-educate them. I did not say not to notify me. They should notify me. During an interview on 12/03/2025 at 5:47 PM, APRN #1 stated, I know him [Resident #51] from [name of another facility]. I get phone calls [from the facility], they can't give me names only room numbers, [Resident #51] has to give me permission to know his name. It [after-hours on-call] is only for emergencies. During an interview on 12/04/2025 at 8:55 AM, Staff C, LPN, stated that [Resident #51's Name] often refused his accu check and his medications. She always called the on-call provider [APRN #1], but she did not always remember to document that she notified the provider. During an interview on 12/04/2025 at 9:10 AM, Staff B, LPN, stated that [Resident #51's Name] did not refuse his medications for her. She thought it was weird that she had charted NA for his blood sugar on the MAR and did not document the amount of insulin she had given for the sliding scale order. She did work the 14th and the 18th [of November 2025]. She must have forgotten to chart some of the details. On the 21st [of October 2025] she stated she forgot to document checking his blood sugar and administering his insulin at 4:30 PM. 8) Review of Resident #70's admission record revealed she was admitted to the facility on [DATE] with medical diagnoses that included cerebrovascular disease, unspecified; type 2 diabetes mellitus with diabetic neuropathy, unspecified; type 2 diabetes mellitus with hyperglycemia; chronic kidney disease, stage 3, unspecified; pressure ulcer of sacral region, stage 4; pressure ulcer of right buttock, stage 2; and a pressure ulcer of left buttock, stage 2. Review of Resident #70's physician orders dated 3/26/2025 read, Lantus Subcutaneous Solution 100 Unit/ML (milliliter) (Insulin Glargine): Inject 36 unit subcutaneously two times a day for diabetic. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105333 If continuation sheet Page 21 of 26 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 105333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at MT Dora, Inc 3050 Brown Ave Mount Dora, FL 32757 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 - Some Review of Resident #70's physician orders dated 12/26/2025 read, Flasp FlexTouch Subcutaneous Solution Pen-Injector 100 Unit/ML (Insulin Aspart (with Niacinamide)): Inject 8 unit subcutaneously with meals related to Type 2 Diabetes Mellitus with diabetic neuropathy, unspecified. Review of Resident #70's MAR/TAR (Medication Administration Record/Treatment Administration Record) for November 2025 read, Lantus Subcutaneous Solution 100 Unit/ML (milliliter) (Insulin Glargine): Inject 36 unit subcutaneously two times a day for diabetic. On 11/03/2025, 11/04/2025, 11/05/2025, 11/07/2025, 11/09/2025, 11/12/2025, 11/13/2025, 11/17/2025, 11/18/2025, 11/19/2025, 11/21/2025, 11/22/2025, 11/23/2025, and 11/26/2025 at 9:00 AM, and 11/04/2025, 11/07/2025, 11/13/2025, 11/16/2025, 11/18/2025, 11/19/2025, 11/22/2025, and 11/26/2025 at 9:00 PM, there was documentation of 2 &ndash; Drug refused. Review of Resident #70's progress notes, including eMAR (electronic Medication Administration) notes revealed there was no documentation of physician/provider notification regarding Resident #70's refusal of Insulin Glargine. Review of Resident #70's MAR/TAR for November 2025 read, Flasp FlexTouch Subcutaneous Solution Pen-Injector 100 Unit/ML (Insulin Aspart (with Niacinamide)): Inject 8 unit subcutaneously with meals related to Type 2 Diabetes Mellitus with diabetic neuropathy, unspecified. On 11/03/2025, 11/04/2025, 11/05/2025, 11/07/2025, 11/09/2025, 11/12/2025, 11/13/2025, 11/17/2025, 11/18/2025, 11/19/2025, 11/21/2025, 11/22/2025, 11/23/2025, 11/25/2025, 11/26/2025 at 8:00 AM; 11/03/2025, 11/04/2025, 11/05/2025, 11/07/2025, 11/09/2025, 11/12/2025, 11/13/2025, 11/17/2025, 11/18/2025, 11/21/2025, 11/22/2025, 11/25/2025, 11/26/2025 at 12:00 PM, and 11/03/2025. 11/04/2025, 11/05/2025, 11/09/2025, 11/11/2025, 11/12/2025, 11/13/2025, 11/17/2025, 11/18/2025, 11/21/2025, 11/22/2025, 11/25/2025, and 11/26/2025 at 5:00 PM, there was documentation of 2 &ndash; Drug refused. Review of Resident #70's MAR/TAR for November 2025 read, Flasp FlexTouch Subcutaneous Solution Pen-Injector 100 Unit/ML (Insulin Aspart (with Niacinamide)): Inject 8 unit subcutaneously three times a day for Diabetes. On 11/30/2025 at 5:00 PM, there was documentation of 2 &ndash; Drug refused. Review of Resident #70's progress notes, including eMAR notes for November 2025 revealed no documentation of physician/provider notification regarding Resident #70's refusal of Insulin Aspart. Review of Resident #70 physician orders dated 11/01/2025, read, Wound care: coccyx cleanse with wound cleanser, pat dry period skin prep peri [around] wound. Apply calcium alginate and cover with silicone super absorbent dressing, every day shift for stage 3 pressure ulcer. This order was discontinued on 11/27/2025. Review of Resident #70's MAR/TAR for November 2025 read, Wound care: coccyx cleanse with wound cleanser, pat dry period skin prep peri wound. Apply calcium alginate and cover with silicone super absorbent dressing, every day shift for stage 3 pressure ulcer. There was no documentation on 11/07/2025, 11/09/2025, 11/11/2025, 11/21/2025, and 11/22/2025. Review of Resident #70 physician orders dated 11/01/2025 read, Wound care: left lateral sacrum cleanse with wound cleanser, pat dry, protect peri wound with skin prep, apply calcium alginate, cover with silicone super absorbent every day shift for shear. This order was discontinued on 11/27/2025. Review of Resident #70's MAR/TAR for November 2025 read, Wound care: left lateral sacrum cleanse with wound cleanser, pat dry, protect peri wound with skin prep, apply calcium alginate, cover with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105333 If continuation sheet Page 22 of 26 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 105333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at MT Dora, Inc 3050 Brown Ave Mount Dora, FL 32757 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 silicone super absorbent every day shift for shear. There was no documentation on 11/01/2025, 11/02/2025, 11/03/2025, and 11/07/2025. Review of Resident #70 physician orders dated 11/21/2025 read, Wound care: Left lateral sacrum skin prep, every day shift for shear. This order was discontinued on 11/27/2025. Residents Affected - Some Review of Resident #70's MAR/TAR for November 2025 read, Wound care: Left lateral sacrum skin prep, every day shift for shear. There was no documentation on 11/21/2025. Review of Resident #70 physician orders dated 2/12/2024 read, Heel protector boots to bilateral heels, while in bed every shift for pressure. This order was discontinued on 11/27/2025. Review of Resident #70's MAR/TAR for November 2025 read, Heel protector boots to bilateral heels, while in bed every shift for pressure. There was no documentation on 11/07/2025 for the second entry/second shift of the day (7:00 PM &ndash; 7:00 AM). Review of Resident #70 physician orders dated 10/31/2025 read, Ketoconazole External Cream 2% (Ketoconazole (Topical)): Apply to R&L buttock topically every day and night shift for MASD for 21 days. This order was discontinued on 11/20/2025. Review of Resident #70's MAR/TAR for November 2025 read, Ketoconazole External Cream 2% (Ketoconazole (Topical)): Apply to R&L buttock topically every day and night shift for MASD for 21 days. There was no documentation on either shift on 11/07/2025. Review of Resident #70 physician orders dated 8/22/2025 read, Wound care: left buttock apply ketoconazole cream, zinc paste every day and evening shift for MASD (moisture-associated skin damage). This order was discontinued on 11/20/2025. Review of Resident #70's MAR/TAR for November 2025 read, Wound care: left buttock apply ketoconazole cream, zinc paste every day and evening shift for MASD. There was no documentation for the day shift on 11/07/2025. Review of Resident #70 physician orders dated 11/21/2025 read, Wound care: left buttock apply zinc paste every day and evening shift for MASD. This order was discontinued on 11/27/2025. Review of Resident #70's MAR/TAR for November 2025 read, Wound care: left buttock apply zinc paste every day and evening shift for MASD. There was no documentation for the day shift on 11/21/2025. Review of Resident #70 physician orders dated 8/22/2025 read, Wound care: Left groin (abdominal fold) apply ketoconazole cream, zinc paste every day and evening shift for unspecified rash. This order was discontinued on 11/20/2025. Review of Resident #70's MAR/TAR for November 2025 read, Wound care: Left groin (abdominal fold) apply ketoconazole cream, zinc paste every day and evening shift for unspecified rash. There was no documentation for day shift on 11/07/2025. Review of Resident #70 physician orders dated 11/21/2025 read, Wound care: Left lower leg apply lac hydrin lotion every day and night shift for xerosis, it was discontinued on 11/27/2025. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105333 If continuation sheet Page 23 of 26 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 105333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at MT Dora, Inc 3050 Brown Ave Mount Dora, FL 32757 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 - Some Review of Resident #70's MAR/TAR (Medication Administration Record/Treatment Administration Record) for November 2025 revealed the following: An entry read, Wound care: Left lower leg apply Lac-Hydrin lotion every day and night shift for xerosis. There was documentation for day or night shift on 11/07/2025. Review of Resident #70 physician orders dated 8/22/2025 read, Wound care: Right buttock apply ketoconazole cream, zinc paste every day and evening shift for MASD. This order was discontinued on 11/20/2025. Review of Resident #70's MAR/TAR for November 2025 read, Wound care: Right buttock apply ketoconazole cream, zinc paste every day and evening shift for MASD. There was no documentation for the day shift on 11/07/2025. Review of Resident #70 physician orders dated 11/21/2025 read, Wound care: Right buttock apply zinc paste every day and evening shift for MASD. This order was discontinued on 11/27/2025. Review of Resident #70's MAR/TAR for November 2025 read, Wound care: Right buttock apply zinc paste every day and evening shift for MASD. There was no documentation for the day shift on 11/21/2025. Review of Resident #70 physician orders dated 8/22/2025 read, Wound care: Right groin (abdominal fold) apply ketoconazole cream, zinc paste every day and evening shift for unspecified rash. This order was discontinued on 11/20/2025. Review of Resident #70's MAR/TAR for November 2025 read, Wound care: Right groin (abdominal fold) apply ketoconazole cream, zinc paste every day and evening shift for unspecified rash. There was no docume FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105333 If continuation sheet Page 24 of 26 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 105333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at MT Dora, Inc 3050 Brown Ave Mount Dora, FL 32757 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain infection control and prevention measures related to medication handling and the use of personal protective equipment (PPE) for three residents (Resident #101, Resident #120, and Resident #121) out of five residents observed for medication administration.Findings include:During an observation on 12/03/2025 at 8:19 AM while Staff A, RN (Registered Nurse) was expelling amlodipine 5 MG (milligrams) Oral Tablet out of the package, it dropped onto the medication cart. Staff A, RN picked up the tablet without donning gloves, placed the pill in the medication cup with several other medications, and administered the medications to Resident #101.During an observation on 12/03/2025 at 8:34 AM Staff A, RN opened a capsule of Lactobacillus acidophilus 10 MG Oral Capsule without wearing gloves and added the contents to a medication cup prior to adding pudding for administration to Resident #120.During an observation on 12/03/2025 at 8:59 AM Staff A, RN donned gloves and administered six medications to Resident #121 via G-Tube (A gastrostomy tube is a tube placed through the abdomen directly into the stomach, used for feeding, administering medication, and draining air or fluid). Staff A, RN failed to don a gown prior to administering medications via Resident #121's G-tube.During an interview on 12/03/2025 at 9:30 AM Staff A, RN stated that she had overlooked wearing a gown while administering medications to Resident #121 via her G-Tube. Staff A. RN should not have picked up Resident #101's amlodipine tablet from the top of the medication cart, especially without wearing gloves, and then administer it to the resident. Staff A, RN was not sure if she should have opened Resident #120's capsule without wearing gloves, but she would wear gloves in the future.During an interview on 12/03/2025 at 9:49 AM the DON stated that residents were on EBP (Enhanced Barrier Precautions) for [intravenous (IV)] lines, G-tubes, and Foleys, PPE (personal protective equipment) was to be worn, including gloves and gowns when in close contact or providing care. A nurse should wear a gown and gloves when administering medications through a peg (Percutaneous Endoscopic Gastrostomy tube, which is a feeding tube inserted through the abdominal wall directly into the stomach) or G-tube. A nurse should not touch pills with their hands. If a resident has an order to open a capsule for administration, the nurse should wear gloves to open or touch the capsule.Review of the policy and procedure, with an issue date of 3/29/2019 and last reviewed date of 1/28/2025, titled Infection prevention and control and surveillance program, read, Policy: It is the policy of the facility to ensure that the infection control program is designed to prevent, identify, report, investigate, and control the spread of infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual agreement; provide a safe, sanitary and comfortable environment; and to help prevent the development and transmission of disease and infection, in accordance with state and federal regulations, and national guidelines. Procedure: . 7. The facility will provide infection prevention and control training upon hire and ongoing throughout the year as needed in the following areas: d. personal protective equipment.Review of the policy and procedure, with an issue date of 4/01/2024 and last review date of 1/28/2025, titled Enhanced Barrier Precautions, read, Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug resistant organisms. Policy explanation and compliance guidelines: 2. Initiation of enhanced barrier precautions:. b. An order for enhanced barrier precautions will be obtained for residents with any of the following: indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO (multidrug-resistant organism) . 4. High-contact resident care activities include: . g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes. Table 1: Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105333 If continuation sheet Page 25 of 26 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 105333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at MT Dora, Inc 3050 Brown Ave Mount Dora, FL 32757 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Implementing Contact versus Enhanced Barrier Precautions:. Resident Status: Has a wound or indwelling medical device, without secretions or excretions that are unable to be covered or contained and are not known to be infected or colonized with any MDRO. Use EBP: Yes.Review of the policy and procedure, with an effective date of 12/01/2007 and last review date of 1/28/2025, titled General Dose Preparation and Medication Administration, read, Applicability: This 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: 1. Facility staff should comply with facility policy, applicable law and the State Operations Manual when administering medications. 2. Prior to preparing or administering medications, authorized and competent facility staff should follow facilities infection control policy. Event ID: Facility ID: 105333 If continuation sheet Page 26 of 26