Health inspection·May 4, 2023

F 0638 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 1. Resident #119 was admitted to the facility on [DATE]. A review of resident #119's medical record revealed the MDS quarterly assessment had an assessment reference date (ARD) of 3/7/23. Review of the history of the quarterly MDS assessment showed it was completed on 5/2/23, locked and accepted on 5/2/23. On 5/4/23 at 12:03 PM, the Licensed Practical Nurse MDS Coordinator C reviewed the resident's medical record and stated her admission/comprehensive MDS assessment was completed and accepted on 12/21/22. The resident's quarterly assessment was due 14 days from the ARD date, 3/7/23. She confirmed the quarterly assessment was not completed and submitted until 5/2/23 and should have been completed on 3/21/23. She acknowledged the assessment was 42 days late. The MDS Coordinator stated she was responsible for ensuring MDS assessments were submitted timely and explained she had just started working at the facility on 5/1/23 and could not explain why the prior MDS nurse did not complete or submit assessments timely. Event ID: Facility ID: 105670 If continuation sheet Page 2 of 15 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 105670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at St Cloud Inc 1301 Kansas Ave Saint Cloud, FL 34769 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to develop, implement, review, and provide a copy of a baseline care plan within 48 hours for 2 of 6 newly admitted residents, of a total sample of 50 residents, (#379, #381). Findings: 1. Resident #379, an [AGE] year-old female, was admitted to the facility on [DATE], with diagnoses including osteomyelitis, hereditary and idiopathic neuropathy, implantable cardiac defibrillator, quadriplegia, and cardiomyopathy. Documentation on the resident's admission Evaluation dated 4/26/23 included, Oxygen continuous 4 Liters. The resident's physician's order dated 4/27/23, noted oxygen, continuous at 3 liters per minute via nasal cannula for a medical diagnosis of pulmonary fibrosis. Review of the resident's clinical record revealed a baseline care plan was not developed to address the information needed to provide effective and person-centered care for resident #379. 2. Resident #381, a [AGE] year-old female, was admitted to the facility on [DATE], with diagnoses which included acute respiratory failure with hypercapnia, obstructive sleep apnea, and diastolic (congestive) heart failure. The resident's hospital Discharge Summary indicated the resident was instructed to use her CPAP (continuous positive airway pressure) . She finally agreed and will continue to use CPAP during sleep and naps. CPAP (continuous positive airway pressure) is a machine that uses mild air pressure to keep breathing airways open while you sleep. (Retrieved on 5/10/23 from ww.nhlbi.nih.gov) Review of the resident's clinical record revealed a baseline care plan was not developed to address resident #381's respiratory status and need for CPAP therapy. On 5/04/23 at 9:45 AM, the Assistant Director of Nursing (ADON) stated baseline care plans were triggered and started by the admitting nurse. On 5/04/23 at 11:51 AM, the Director of Nursing (DON) stated baseline care plans should address the resident's immediate needs and were imbedded in the admission Evaluation form completed by nursing at admission. The DON explained that baseline care plans should identify the resident's respiratory status and indicate the use of any devices. She said the Paper baseline care plans for residents #379 and resident #381 were used by the Minimum Data Set (MDS) Coordinator in the welcome care plan meetings done following the residents' admission. Section H of resident #379's admission Evaluation with effective date of 4/26/23 at 6:40 PM, and signed date of 4/27/23 was reviewed with the DON. She confirmed the evaluation revealed resident #379 used oxygen continuously. The DON acknowledged resident #381's admission Evaluation form with effective date of 4/24/23 at 8:30 PM, did not identify CPAP (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105670 If continuation sheet Page 3 of 15 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 105670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at St Cloud Inc 1301 Kansas Ave Saint Cloud, FL 34769 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few for the resident in section H -respiratory or section M-sleep patterns. Resident #379's baseline care plan dated 4/28/23 was reviewed with the DON. Areas were checked off for advance directives, nutrition/hydration, and the document indicated the resident required therapy to achieve her previous level of function. The DON validated the baseline care plan did not address the resident's respiratory status and need for continuous oxygen therapy. A signature, or date was not identified to indicate the baseline care plan was acknowledged, and that a written summary of the baseline care plan was provided to the resident/responsible party. Resident #381's baseline care plan dated 4/28/23 did not identify the need for CPAP therapy. The DON confirmed that resident #381's baseline care plan was not developed within 48 hours of her admission and did not address her need for CPAP. On 5/04/23 at 2:05 PM, Licensed Practical Nurse (LPN) Minimum Data Set (MDS) Coordinator G stated baseline care plans were initiated by the admitting nurse, then MDS would review the resident's orders and adjust the care plan as needed. LPN MDS Coordinator G verbalized baseline care plan would be discussed with the resident/family/responsible party within three days of the resident's admission. She stated she was not aware that a baseline care plan should be developed and implemented within 48 hours of the resident's admission. LPN MDS Coordinator G acknowledged a signature and date was not on resident #379's baseline care plan to indicate it was reviewed, and that a copy was provided to the resident/responsible party. She confirmed that resident #381's baseline care plan was not developed within 48 hours of the resident's admission. The facility's policy Baseline Care Plan not dated, read, The baseline care plan must include the minimum healthcare information necessary to properly care for each resident immediately upon their admission . The baseline care plan must: Be developed within 48 hours of a resident's admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105670 If continuation sheet Page 4 of 15 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 105670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at St Cloud Inc 1301 Kansas Ave Saint Cloud, FL 34769 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive care plan for Continuous Positive Airway Pressure (CPAP) therapy for 1 of 4 residents reviewed for respiratory care and services, out of a total sample of 12 residents, (#381). Findings: Review of the medical record revealed resident #381 was admitted to the facility on [DATE] with diagnoses including obstructive sleep apnea, primary pulmonary hypertension, and acute respiratory failure. The Minimum Data Set (MDS) admission assessment with assessment reference date of 4/26/23 revealed resident #381 used a non-invasive mechanical ventilator such as a CPAP. The Order Summary Report revealed resident #381 had a physician's order dated 5/02/23 for CPAP therapy at Auto 8 to 18 setting for sleep apnea. A CPAP machine has a motor that blows air through a tube connected to a mask which fits over the nose and/or mouth. The machine maintains mild air pressure to keep airways open during sleep. The device is often prescribed by a physician to treat sleep-related breathing disorders including sleep apnea (retrieved on 6/13/23 from www.nhlbi.nih.gov/health/cpap). Resident #381's comprehensive care plan read, Last Care Plan Review Completed: 5/23/23. Review of the document revealed no care plan focus areas related to respiratory care and services including CPAP therapy. Review of the facility's policy and procedure Comprehensive Care Plans revised on 3/02/19, revealed the facility's goal was to provide appropriate care for residents by utilization of an interdisciplinary plan of care. The document read, The care plan will identify priority problems and needs to be addressed by the interdisciplinary team, and will reflect the resident's strengths, limitations and goals. The care plan will be complete, current, realistic, time specific and appropriate to the individual needs for each resident.consistent with the medical plan of care. The policy indicated each discipline was responsible for reviewing and revising the care plan to reflect interventions necessary to promote the resident's well-being. On 6/06/23 at 11:58 AM, the Regional Director of Clinical Services (RDCS) was informed that resident #381's medical record showed a diagnosis of sleep apnea and a physician order for CPAP therapy, but there was no associated care plan for CPAP therapy or respiratory issues. The RDCS explained staff should have initiated a care plan for the resident's CPAP use and respiratory issues. On 6/06/23 at 12:11 PM, the MDS Coordinator stated each department was expected to initiate or update appropriate care plans for each resident as indicated. She confirmed the clinical team, specifically the Nursing department, was responsible for ensuring resident #381 had a comprehensive care plan for CPAP therapy. The MDS Coordinator acknowledged she oversaw the care planning process and missed the absence of a care plan for the resident's respiratory diagnoses and CPAP. She explained comprehensive care plans were important as the goals and interventions reflected the resident's essential (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105670 If continuation sheet Page 5 of 15 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 105670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at St Cloud Inc 1301 Kansas Ave Saint Cloud, FL 34769 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 care needs. Level of Harm - Minimal harm or potential for actual harm Review of the Facility Assessment revised on 3/02/19, revealed facility staff would demonstrate competency in the provision of specialized care and person-centered care to include care planning. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105670 If continuation sheet Page 6 of 15 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 105670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at St Cloud Inc 1301 Kansas Ave Saint Cloud, FL 34769 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure notification to provider for elevated blood glucose, and failed to ensure orders were received and implemented timely for treatment of elevated blood glucose levels for 1 of 1 resident reviewed for quality of care, of a total sample of 50 residents, (#382). Residents Affected - Some Findings: Resident #382, an [AGE] year-old female was admitted to the facility on [DATE]. Her diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, aphasia, convulsions, Alzheimer's disease, diabetes type II, gastrostomy, and metabolic encephalopathy. Review of resident #382's hospital history and physical dated 4/06/23 revealed the resident's Current Outpatient Medications included Insulin Aspart (Novolog) 20 units three times daily, Lantus, and Januvia 50 milligram. The hospital discharge orders listed Insulin Lantus 20 units daily. Review of the resident's Physician Progress Note documented by the Advanced Practice Registered Nurse (APRN) dated 5/02/23 revealed the resident's past medical history included diabetes. The past medications included insulins Lantus and Humalog. Documentation revealed the APRN assessment indicated the resident had diabetes type II, and the documented plan was to monitor blood glucose levels. Review of resident #382's physician orders revealed an order dated 4/29/23 for Lantus 20 units daily. There were no orders for any additional insulin, or for blood glucose monitoring. On 5/03/23 at 12:16 PM, resident #382's daughter stated the resident had diabetes for over thirty years. She noted before her admission to the facility, she received insulin three times daily. The daughter verbalized that approximately one hour ago, the resident was sweating bullets. She stated Licensed Practical Nurse (LPN) A monitored the resident's blood glucose, and it was over 500. The resident's daughter said the facility did not have an order for insulin for the resident, and she was told they would need to call the physician to obtain an order. On 5/03/23 at 12:21 PM, LPN A was standing at her medication cart. She explained she was monitoring blood glucose, and preparing insulin for other residents. When asked about resident #382's blood glucose, the LPN stated someone was at the desk calling the physician for an insulin order. On 5/03/23 at 12:25 PM, the Director of Nursing (DON) stated she was not aware of the resident's elevated blood glucose. A review of the resident's current physician orders revealed an order for insulin Lantus daily. An order for blood glucose monitoring, or any additional insulin could not be identified. The DON stated when the resident was in the hospital, she required two types of insulin, Lantus, and Novolog, along with oral Januvia. She stated the resident's labs completed on 5/01/23 showed her blood glucose was high, with a result of 213. The lab report indicated blood glucose was considered normal between 70-99. The DON stated the labs were reviewed by the ARNP, and no new orders were placed. On 5/03/23 at 12:45 PM, LPN A stated the Advance Practice Registered Nurse (APRN) gave orders to administer 10 units of regular insulin to the resident and then recheck her blood glucose. On 05/03/23 at 12:59 PM, LPN A recalled when she walked into the resident's room to provide nursing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105670 If continuation sheet Page 7 of 15 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 105670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at St Cloud Inc 1301 Kansas Ave Saint Cloud, FL 34769 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 - Some care, the resident was sweaty. She said she removed her blanket, and checked her blood glucose which was high, registering 572 on the glucometer. The LPN stated she reviewed the physician orders for sliding scale protocol to administer insulin to the resident, but an order was not in place. She explained that she tried to get one of the other nurses on the unit to call the physician, but they did not get to call, so she called the physician, and received an order for insulin. LPN A stated a recheck of the resident's blood glucose revealed it was still high at 555. Regular insulin 10 units was administered to the resident at 1:00 PM. On 5/03/23 at 2:33 PM, the DON stated that if a resident's blood glucose was elevated, and there were no orders for insulin, the expectation was the physician would be notified within fifteen to thirty minutes. On 05/03/23 at 2:55 PM, LPN A, noted that when she monitored the resident's blood glucose and the result was 572, and after she reviewed the physician's orders and a sliding scale insulin order was not identified, she called over to the A Wing for assistance but ended up calling the physician herself at approximately 12:27 PM. LPN A could not recall what time she monitored the resident's blood glucose. Both glucometers on the nurses' medication cart was checked, and the history showed the residents blood glucose was monitored at 11:19 AM. Observation revealed the resident's blood glucose was rechecked at 12:56 PM. LPN A confirmed the resident was not treated for her elevated blood glucose in a timely manner. When asked the expectation for monitoring and treatment for elevated blood glucose, the LPN did not have a response. She then verbalized she should have stopped what she was doing and addressed the resident's elevated blood glucose in a timely manner. The resident's blood glucose was 572 at 11:19 AM, and she did not receive insulin until 1:00 PM, one hour and forty-one minutes after her blood glucose was monitored. On 5/04/23 at 10:06 AM, the ARNP stated the facility called her regarding resident #382's elevated blood glucose, and she gave an order for 10 units of regular insulin and for sliding scale protocol. The ARNP stated that when a resident has a diagnosis of diabetes, they were usually placed on blood glucose monitoring. She said somehow it was missed for the resident. She said if the blood glucose was critical/high, the expectation was for the physician/provider to be notified immediately, so orders could be obtained to treat the condition. On 5/04/23 at 11:51 AM, the DON stated it would be a reasonable assumption that blood glucose monitoring should be requested for residents receiving insulin. The facility did not have a policy that addressed blood glucose monitoring/diabetic management. The L.P.N. Competency Skills Checklist dated 12/29/22 indicated LPN A was competent to provide nursing care based on scientific principles and sound theoretical knowledge FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105670 If continuation sheet Page 8 of 15 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 105670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at St Cloud Inc 1301 Kansas Ave Saint Cloud, FL 34769 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 physician orders were obtained and entered correctly in the electronic medical record for Continuous Positive Airway Pressure (CPAP) therapy for 1 of 4 residents reviewed for respiratory care, (#381); failed to ensure Oxygen (O2) therapy was administered per physician orders for 1 of 4 residents reviewed for respiratory care, (#379); and failed to ensure oxygen concentrators were maintained in clean and safe condition for 1 of 4 residents reviewed for respiratory care, of a total sample of 50 residents, (#93). Residents Affected - Few Findings: 1. Resident #381, a [AGE] year-old female, was admitted to the facility on [DATE], with diagnoses which included acute respiratory failure with hypercapnia, obstructive sleep apnea, and diastolic (congestive) heart failure. The Hospital Discharge Summary with date of service 4/22/23 read, Patient instructed to use her CPAP at settings of 15/8. She finally agreed and will continue to use CPAP during sleep and naps. CPAP (continuous positive airway pressure) is a machine that uses mild air pressure to keep breathing airways open while you sleep. (Retrieved on 5/10/23 from ww.nhlbi.nih.gov) Review of the resident's physician's orders revealed an order dated 4/25/23 for CPAP one-time only for one day. Progress note dated 5/01/23 read, Resident received in bed watching TV in room with CPAP on .O2:95% on CPAP. On 5/01/23 at 2:16 PM, resident #381 was lying on her back in bed. A CPAP machine was on her bedside table, and the resident stated it was placed on during the nights. On 5/02/23 at 4:47 PM, and at 5:31 PM, the Director of Nursing (DON) recalled that when the resident was admitted to the facility, the CPAP order was faxed over to the company, who delivered the machine with the prescribed settings in place. A review of the resident's current physician's orders with the DON noted an order for CPAP could not be found. The resident's discontinued/completed physician's orders were reviewed, and revealed a one-time order for CPAP dated 4/25/23, scheduled for one day only. The DON stated the order for the resident's CPAP therapy was placed incorrectly, and should have been scheduled for every night, and not for one day. A review of the resident's progress notes revealed a note dated 5/01/23 indicated the CPAP machine was used for the resident. This was confirmed by the DON, who stated she would notify the physician of the transcription error. She stated she spoke with the resident, and the resident told her the CPAP was placed on her at nights. The DON explained that all new admission clinical records were reviewed the following day in the morning clinical meeting, and those admitted over the weekend would be reviewed on Monday. She stated the records were reviewed to ensure they were complete and accurate. She said resident #381's clinical records were reviewed to ensure the CPAP order was in, but the order was not reviewed for accuracy. 2 Resident #379, an [AGE] year-old female, was admitted to the facility on [DATE], with diagnoses including osteomyelitis, hereditary and idiopathic neuropathy, implantable cardiac defibrillator, quadriplegia, and cardiomyopathy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105670 If continuation sheet Page 9 of 15 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 105670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at St Cloud Inc 1301 Kansas Ave Saint Cloud, FL 34769 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 Level of Harm - Minimal harm or potential for actual harm Review of the resident's current physician's orders revealed an order dated 4/27/23 for oxygen (O2) continuous at 3 liters per minute (LPM) via nasal cannula for diagnosis of pulmonary fibrosis. On 5/01/23 at 10:40 AM, and on 5/01/23 at 2:04 PM, resident #379 received O2 via nasal cannula at 4 LPM. Residents Affected - Few On 5/01/23 at 2:20 PM, Licensed Practical Nurse (LPN) A stated resident #379 received O2 therapy via nasal cannula. The LPN reviewed the resident's current physician's orders, and stated the resident had an order for oxygen at 3 LPM. The resident's O2 flow rate was observed with LPN A. She confirmed the O2 was infusing at 4 LPM. LPN A stated O2 was a physician's order and should be checked during medication administration. She stated she did not check the resident's O2 to ensure the O2 was infusing at the ordered flow rate. On 5/01/23 at 3:20 PM, the DON stated that a review of the resident's hospital records revealed the resident received O2 at 4 LPM while in the hospital, and stated the order in place was a transcription error by the nurse and should have been for 4 LPM, instead of 3 LPM. The resident's Baseline care plan dated 4/28/23, did not address the resident's diagnosis and need for O2 therapy. The facility's policy Physician Services issued 3/02/19 read, 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. 3. Resident #93 was admitted to the facility on [DATE] with diagnoses of atrial fibrillation, diabetes mellitus, ventricular tachycardia, and hypertension. On 5/1/23 at 10:30 AM, resident #93 was observed in bed. He did not have oxygen applied as the nasal cannula (NC) was draped over the bed rail. The tubing was attached to dirty oxygen concentrator. The side removable filter of the concentrator was covered with a thick layer of gray dust particles. The resident verbalized he did not want to wear his oxygen because the tubing was making his ears sore. The oxygen flow rate was set at 2 liters per minute (LPM). A review of the physician orders dated 11/6/22 noted oxygen at 2 LPM via NC for SOB (shortness of breath)/Sats (saturation) less than 92%, rinse and replace oxygen filters on concentrator q (every) night shift on Saturday and oxygen Sat every shift prn (as needed), and call MD (Medical Doctor) if less than 90%. Resident #93 had a care plan, created 1/6/23, for oxygen therapy related to SOB, included interventions to change equipment as per recommendation or protocol and goal for resident was to maintain use of oxygen without complications. On 5/2/23 at 11:02 AM, resident #93 was observed again in bed and not wearing his oxygen as the NC was draped over the bed rail and the concentrator was running at 2 LPM. The side removable filter of the concentrator was still covered with thick layer of gray dust particles. Again, he voiced he was not wearing oxygen due to his ears being sore from the tubing. He agreed for surveyor to report ear soreness to his nurse. On 5/2/23 at 11:05 AM, assigned Registered Nurse (RN) B was informed that resident #93 wanted (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105670 If continuation sheet Page 10 of 15 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 105670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at St Cloud Inc 1301 Kansas Ave Saint Cloud, FL 34769 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few foam/cushion on oxygen tubing because his ears were sore. She agreed to put either gauze or foam on the tubing where it was bothering his ears. On 5/3/23 at 10:43 AM, resident #93 was observed lying in bed wearing oxygen tubing that now had cushion taped near the ears. The tubing was connected to a dirty concentrator with thick layer of gray dust particles still present on the removable side filter. The assigned nurse, RN B was present in the room. On 5/3/23 at 1:55 PM, resident #93 wore the NC which was attached to the oxygen concentrator at bedside. The side filter of the machine was unchanged, and RN B acknowledged it was dirty. RN B said, she thought maintenance staff were responsible to clean the oxygen contractor filters and not the nursing staff. She did not know how often the filters should be cleaned and acknowledged she did not notice the dirty filter today or yesterday when assigned to resident #93. On 5/3/23 at 2:15 PM, the Director of Plant Operation validated resident #93's dirty oxygen concentrator filter. He said housekeeping staff were responsible to clean the concentrator and filters but there was no particular cleaning schedule. On 5/3/23 at 2:40 PM, the Manager of Housekeeping and Laundry validated resident #93 had dirty oxygen concentrator with thick layer of gray dust on the side filter. He said, any staff who saw the filter was dirty should have cleaned it. He noted there was no cleaning schedule. On 5/3/23 at 3:15 PM, the Director of Nursing (DON) said, the nursing staff should clean oxygen concentrator filters weekly when they change oxygen tubing. She explained it was not the responsibility of housekeeping or maintenance staff. On 5/3/23 at 3:23 PM, the DON said she provided incorrect information and noted it was the housekeeping staff's responsibility to clean oxygen filters and not the nursing staff. She added, there is no policy regarding who was responsible or how often. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105670 If continuation sheet Page 11 of 15 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 105670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at St Cloud Inc 1301 Kansas Ave Saint Cloud, FL 34769 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. 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 ongoing communication, coordination and collaboration between the nursing home and the dialysis center for 1 of 1 resident reviewed for dialysis of a total sample of 50, (#8). Residents Affected - Few Findings: Resident #8 was admitted to the facility on [DATE] with diagnoses including end stage renal disease, clostridium difficile, sepsis, dilated cardiomyopathy, human immunodeficiency virus, viral hepatitis, hypovolemic shock and adult failure to thrive. Review of the Minimum Data Set admission assessment with assessment reference date 4/07/23 revealed resident #8 had a Brief Interview for Mental Status score of 14 which indicated she was cognitively intact. She required total assistance for activities of daily living and did not reject care. The document indicated resident #8 had an active diagnosis of end stage renal disease and received dialysis. Review of resident #8's medical record revealed a physician order dated 5/01/23 for hemodialysis at an outside facility on Monday, Wednesday and Friday at 2:00 PM. Hemodialysis is a procedure where a dialysis machine and special filter are used to remove wastes and fluids from the blood to keep a person healthy when the kidneys no longer function properly (retrieved 5/05/23 from the National Kidney Foundation website at www.kidney.org). A care plan initiated 3/30/23 indicated resident #8 had a need for hemodialysis related to renal failure. Interventions included hemodialysis at an outside center on Monday, Wednesday and Friday at 2:00 PM. The care plan did not include any interventions or approaches for communication, coordination and collaboration between the facility and the dialysis center. A review of resident #8's physical chart revealed the chart did not include any Dialysis Communication forms. A review of the Progress Notes from 3/30/23 through 5/03/23 revealed no documentation the facility communicated with the dialysis center regarding pre-treatment and post-treatment weights and vitals signs, access problems, medications given prior to dialysis treatment, medications given during/after treatment, change in condition or special instructions. On 5/03/23 at 1:30 PM, Registered Nurse (RN) D stated resident #8 was on antibiotic therapy for an infection. She confirmed resident #8 received dialysis on Monday, Wednesday and Friday. She stated there was a notebook with dialysis communication forms in it at the nurse station. RN D looked in the notebook and confirmed the communication forms were blank. She acknowledged she did not know where the completed communication forms were located. On 5/03/23 at 1:37 PM, the Assistant Director of Nursing (ADON) stated the dialysis communication forms may have been sent to the medical records department. On 5/03/23 at 4:05 PM, the Health Information Records Tech in the medical records department stated she did not recall receiving any dialysis communication forms for resident #8. She reviewed the forms in her folders but could not locate any dialysis communication forms. The Health Information (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105670 If continuation sheet Page 12 of 15 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 105670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at St Cloud Inc 1301 Kansas Ave Saint Cloud, FL 34769 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Records Tech reviewed the electronic medical record (EMR) and confirmed no dialysis communication forms were scanned into resident #8's EMR. On 5/03/23 at 4:34 PM, Licensed Practical Nurse (LPN) A, RN E and LPN F were at the nurse station for resident #8. LPN A, RN E and LPN F did not explain how the facility ensured ongoing communication and collaboration between the facility and dialysis center. LPN A reviewed the medical chart and confirmed there were no communication forms present. LPN A and LPN F looked in the dialysis book and confirmed the communication forms in the notebook were blank. RN E and LPN F searched through the file cabinet at the nurse station and could not locate any documentation to show communication between the facility and the dialysis center. On 5/03/23 at 4:42 PM, the Director of Nursing (DON) stated the facility no longer sent communication forms to the dialysis center because the dialysis center would not complete them. She stated the facility communicated with the dialysis center often but was unable to produce any documentation to show communication between the facility and the dialysis center. On 5/03/23 at 4:56 PM, the DON stated she was on the phone with the Dialysis Center Administrator and the center was going to fax the weight sheets for resident #8's dialysis visits. The DON acknowledged she did not have the pre-treatment and post-treatment weights prior to this date. In a telephone interview on 5/03/23 at 4:58 PM, the Dialysis Center Administrator confirmed the dialysis center did not complete communication forms between them and the facility. She stated she received information from her technicians but had not spoken with the facility. The Dialysis Center Administrator acknowledged she was not aware the resident had an infection or was taking any antibiotics. The facility's Dialysis policy and procedure dated 3/02/19 read, The facility and the Dialysis Center should maintain regular communication and should a change in condition occur before or during the dialysis treatment, the sending facility should communicate the changes in needs to the receiving facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105670 If continuation sheet Page 13 of 15 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 105670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at St Cloud Inc 1301 Kansas Ave Saint Cloud, FL 34769 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on observation, interview, and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee developed and implemented effective Performance Improvement Plans (PIPs) to correct and monitor identified deficiencies. Findings: On 6/06/23 at 11:58 AM, the Regional Director of Clinical Services (RDCS) confirmed the facility's QAPI committee implemented PIPs to address noncompliance identified during the facility's recertification survey which ended on 5/04/23. She was informed of a repeat concern related to respiratory care and services for Continuous Positive Airway Pressure (CPAP) therapy with the same resident identified during the recertification survey. The RDCS validated the concern related to use and monitoring of the respiratory device. She explained Unit Managers (UMs) were responsible for auditing residents' medical records to ensure accuracy, but there was no UM on that resident's unit at this time. She acknowledged there was only one resident in the facility who had a CPAP machine and the PIP involved a weekly audit of the resident's physician orders. The RDCS could not explain why the audit had not captured the issue. On 6/06/23 at 12:11 PM, the Minimum Data Set (MDS) Coordinator validated a concern identified regarding lack of a comprehensive care plan for respiratory care and services for the resident who required CPAP therapy. She confirmed there was a deficiency from the recent recertification survey as the resident did not have a baseline care plan for CPAP therapy. The MDS Coordinator acknowledged this resident's comprehensive care plans had since been developed but still did not include care plans for her respiratory care needs including CPAP therapy. On 6/06/23 at 1:38 PM, the facility's Director of Nursing (DON) was informed of a repeat concern regarding a resident who had oxygen administered at the wrong flow rate. She confirmed there was an audit in place and nurses were responsible for ensuring residents received oxygen at the flow rate ordered. The DON was unsure if a member of the QAPI committee regularly checked settings to verify accuracy. On 6/06/23 at 2:43 PM, the RDCS validated a concern identified related to failure to monitor a resident's blood glucose levels as ordered for approximately six months. She confirmed it was a significant finding as the discrepancy had gone unnoticed by all assigned nurses and nurse management staff over that period of time. During review of the QAPI binder with the RDCS, she confirmed the affected resident was listed on an audit form that showed his medical record was reviewed specifically for the plan of care related to diabetes management. The RDCS confirmed the whole house audit of all diabetic residents was conducted as part of a PIP to address noncompliance identified during the facility's recertification survey. The RDCS could not explain why the audit had not captured the issue. On 6/06/23 at 4:33 PM, an interview was conducted with the facility's Administrator, RDCS, and Director of Nursing (DON) to discuss repeat deficient practices identified during the revisit survey. On 6/06/23 at approximately 4:36 PM, the Administrator stated the facility developed and initiated PIPs on 5/05/23 to correct deficiencies identified during the recertification survey. She explained the PIPs were created by all members of the QAPI team in conjunction with the corporate office. The Administrator recalled the QAPI committee met again on 5/31/23 to discuss the facility's plan of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105670 If continuation sheet Page 14 of 15 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 105670 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at St Cloud Inc 1301 Kansas Ave Saint Cloud, FL 34769 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some correction and audit findings. She stated the committee modified the audit tools, but she was not aware the audit tools had not captured all necessary data to ensure compliance. The Administrator confirmed she led the QAPI committee which was tasked with ensuring success of PIPs. When asked why repeat and/or continued deficient practices were not identified during weekly audits, the Administrator said, Our audit tools were not effective. She stated the revisit survey findings indicated audit tools needed to be reviewed and revised by the QAPI committee. On 6/06/23 at approximately 4:40 PM, the DON stated in response to the concerns identified, the facility would have to conduct another whole house audit of diabetic residents to ensure blood glucose was monitored as ordered. The DON acknowledged the QAPI committee would also have to address the issues of inaccurate transcription of physician orders in the electronic medical record and nursing standards of practice related to reading orders and documentation. On 6/06/23 at approximately 4:43 PM, the RDCS confirmed all areas of deficient practice identified during the revisit survey involved residents who were reviewed during QAPI committee audits. Review of the facility's policy and procedure for Quality Assurance and Performance Improvement revised on 3/02/19 read, The facility will develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life. The document indicated the facility would develop corrective action plans, implement performance improvement activities, and measure the effectiveness of those actions to ensure desired results were achieved and sustained. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105670 If continuation sheet Page 15 of 15