Inspection·June 15, 2023

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement the process to ensure resident's wishes related to advance directives were accurately recorded for 1 of 1 sampled residents out of a total sample of 35 residents, (#22). Findings: Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of stroke, type 2 diabetes, bipolar disorder, and dementia. Review of the resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date of [DATE] revealed the resident's cognition was intact with a Brief Interview for Mental Status score of 13/15. The assessment noted resident #1's hearing was adequate, his speech was clear and he made himself understood with clear comprehension. The assessment noted his vision was severely impaired. On [DATE] at 10:19 AM, resident #22 stated he wanted to be resuscitated and everything to be done if his heart stopped beating or he stopped breathing. He explained he told the nurse his wishes when he came back from the hospital that he wanted full code. He stated years ago I did not care but now I want to live. Review of the physician orders for resident #22 dated [DATE], read, Do Not Resuscitate. A progress note dated [DATE] at 8:07 PM, read, The resident has chosen to be a full code and to receive CPR. Review of the medical record revealed no documentation of a discussion between Social Services and the resident about his wishes for CPR. On [DATE] at 11:18 AM, the Director of Nursing (DON) was informed there was a note in the resident's medical record that indicated he requested to be full code when he returned from the hospital in February. She explained she should have been informed and a meeting held with the resident, and his Power of Attorney and to discuss the change in advance directive. She stated she was not made aware. On [DATE] at 10:15 AM, the MDS coordinator stated advance directives were discussed at the care plan meetings. She indicated the resident was not invited to the care plan meeting as he had a POA. She noted the POA had attended the initial meeting but none since then. She acknowledged the resident was evaluated to be cognitively intact and should have been given the opportunity to disclose his desires for advance directives with the POA present at the meeting. Review of the facility Advanced Directive Policy issued and revised, 02/2019 read: Social Services or the appropriate designee should visit the resident and discuss advance directives with them to ensure that he/she has executed the advance directives that he/she would want. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105671 If continuation sheet Page 2 of 13 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 105671 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at Melbourne Inc 1420 South Oak Street Melbourne, FL 32901 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to complete a Preadmission Screening and Resident Review (PASRR) for newly evident possible Serious Mental Illness (SMI) for 2 of 2 sampled residents from a total sample of 35 residents, (#81, #7). Findings: 1. Review of resident #81's medical record revealed the resident was admitted to the facility on [DATE] from a rehabilitation hospital and had diagnoses that included metabolic encephalopathy (brain function abnormality), depression, atrial fibrillation (heart dysfunction), and abnormal liver chemistry. Diagnoses of paranoid personality disorder, cognitive communication deficit, need for assistance with personal care, dysphagia (swallowing difficulty) and malnutrition were added to the resident's plan of care after he was admitted . The medical record revealed a PASRR was completed on 4/11/2023 by acute care hospital staff. Section I noted there were no suspected or Mental Illness (MI) present. The record showed the diagnosis of paranoid personality disorder was added to resident #81's plan of care by the psychiatric provider on 5/04/2023. On 6/14/2023 at 10:27 AM, the Director of Nursing (DON) said residents' PASRRs were reviewed by Admissions Coordinator and the documents were scanned to the resident's medical record. She explained nursing was responsible for any updates after that and she worked along with Social Services to ensure they were completed. On 6/14/2023 4:30 PM, the DON provided a copy of the level 1 PASRR completed on 4/11/2023 that was in the resident's medical record. She acknowledged the document had not included any known or possible mental illnesses. She said on 5/03/2023 the resident was diagnosed with mental illness and another PASRR should have been completed for further evaluation for possible additional services or alternative placement. She explained she was the designated PASRR screener for the facility. 2. Resident #7's medical record revealed the resident was admitted to the facility on [DATE] from an acute care hospital with diagnoses of polyneuropathy, neuromuscular dysfunction, bipolar disorder, and mild cognitive impairment. A level I PASRR screen was completed on 8/20/20 by acute care hospital staff. Section IV noted there was no Mental Illness (MI) present or indicated. The medical record showed the diagnosis of Schizoaffective Disorder, Bipolar was added to resident #81's plan of care, effective 1/17/2023. On 6/14/2023 at 4:31 PM, the DON provided a copy of resident #7's level 1 PASRR located in the resident's medical record. She acknowledged the document did not include any known or possible mental illness. She said the resident had a diagnosis included on the list of MI in Section I, and another screen should have been completed to ensure further evaluation for additional services and alternative placement was not required. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105671 If continuation sheet Page 3 of 13 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 105671 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at Melbourne Inc 1420 South Oak Street Melbourne, FL 32901 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 0644 Review of the facility's policies and procedures titled, PASRR, dated 7/28/2022, read, . If the PASRR Level I outcome is positive, then a PASRR Level II evaluation and determination must be completed . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105671 If continuation sheet Page 4 of 13 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 105671 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at Melbourne Inc 1420 South Oak Street Melbourne, FL 32901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Pre-admission Screen and Resident Review (PASRR) was completed prior to admission or as soon as identified after admission for 1 of 3 residents reviewed for Pre-admission Screen and Resident Review out of a total sample of 35 residents, (#2) Residents Affected - Few Findings: Review of the medical record for resident #2 revealed she was admitted to the facility on [DATE] from another facility with diagnoses of paranoid schizophrenia, hypothyroidism, drug induced subacute dyskinesia, and depressive disorder. Review of the Minimum Data Set (MDS) quarterly assessment with an assessment reference date of 5/24/23 showed no PASRR screening and noted the resident had moderate cognitive impairment with a Brief Interview for Mental Status score of 8 out of 15. The medical record contained a PASRR screening form with no date, and blank pages except for resident #2's name, age, social security number and date of birth . On 6/14/23 at 10:23 AM, the Director of Nursing (DON) stated the Admissions Coordinator was responsible for the PASRR including scanning the PASRR form into the electric record. She stated she was responsible for for the screening and care services. On 6/14/23 at 1:55 PM, Director of Admissions stated the facility received the completed PASRR form from the hospital before the resident is admitted . If the PASRR comes in and is not completed, then the form is taken to the DON so a nurse can make sure it is completed before the resident arrives from the hospital. On 6/14/23 at 1:59 PM, the Social Services Director stated nursing was responsible for completing the PASRR. She noted if additional screening was needed, it was the responsibility of the nursing department. She stated PASRR audits were done by Social Services by checking all records in the facility. She stated the last complete audit for PASRR was 4/17/23. Upon review of resident #2's PASRR with the Social Services Director, she validated the form was blank and not completed. She stated she had requested the previous unit manger to complete the PASRR audit. She stated I started it but did not complete it which is probably how it was missed. On 6/14/23 at 5:20 PM, the DON stated she was responsible for completing the PASRR. She noted resident #2 had resided in the facility for 1 year, 6 months, and 26 days without having a Pre-admission Screen and Resident Review completed. Review of the facility's policies and procedures PASRR revised 7/28/22 revealed Kepro contracts with AHCA to serve a the Florid PASRR Level I and Level II vendor. For individuals residing in a community setting. Kepro has been delegated by AHCA to complete onsite PASRR Level I screening. If the PASRR Level I outcome is positive, then a PASRR Level II evaluation and determination must be completed prior to a Medicaid-certified nursing home admission, regardless of payor source. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105671 If continuation sheet Page 5 of 13 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 105671 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at Melbourne Inc 1420 South Oak Street Melbourne, FL 32901 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to review or revise the individualized smoking safety plan of care for 2 out of 4 residents reviewed for care plans, from a total sample of 35 residents, (#18, #21). Findings: 1. Review of the medical record revealed resident #18 was admitted to the facility from an acute care hospital on 6/24/2019 and had diagnoses that included nicotine cigarette dependence, borderline intellectual functioning, schizoaffective disorder, bipolar disorder, dementia, epilepsy, chronic obstructive pulmonary disease (impaired lung functioning), and muscle weakness. The Minimum Data Set (MDS) with Assessment Reference Date (ARD) 5/29/2023 noted the resident scored 7 out of 15 on the Brief Interview for Mental Status (BIMS), that indicated he was cognitively impaired. The assessment noted the resident showed indicators of psychosis with hallucinations and delusions, required staff assistance to complete Activities of Daily Living (ADL), and received antipsychotic medications for 3 days, and antidepressant medications for 7 days out of 7 days of the look back period. The comprehensive care plan included focus items for supervised cigarette smoking with potential for injury and an intervention to evaluate for safety at least every 3 months, monitoring of disorganized thought processes, paranoid and auditory hallucinations, anxiety, and falling asleep while sitting in a chair with interventions that required staff to frequently redirect and support him. On 6/14/2023 at 11:32 AM, the Director of Nursing (DON) explained the facility had a process that determined safety and individual risks associated with residents who chose to smoke cigarettes. She said a nurse completed an assessment when residents were admitted , and no less than every 3 months thereafter. She said it was very important to continually re-evaluate residents' plan of care for changes, declines, or concerns for potential to cause injury or harm. She checked resident #18's medical record and acknowledged the last smoking assessment was completed on 11/28/2022 and it noted the resident may not smoke unsupervised. She said there were 2 missing assessments since that time, and she could not explain why they had not been done. 2. Review of the medical record revealed resident #21 was admitted to the facility from an acute care hospital on [DATE] and had diagnoses that included nicotine cigarette dependence, chronic respiratory failure, non-compliance with regimens, supplemental oxygen dependence, and depression. The MDS with ARD 4/01/2023 noted the resident scored 14 out of 15 on the BIMS, that indicated his cognition was intact. The assessment noted he required extensive staff assistance to complete ADLs, had range of motion deficits to both sides of his lower body, and he received antidepressant and opioid medications for 7 days out of 7 during the look back period. The comprehensive care plan included focus items for cigarette smoking with potential for injury and interventions to monitor for non-compliance because he allowed other residents to access his smoking products and materials, evaluate for safety at least every 3 months, monitoring of impaired cognition, thought processes, outbursts towards other residents, and poor safety awareness with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105671 If continuation sheet Page 6 of 13 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 105671 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at Melbourne Inc 1420 South Oak Street Melbourne, FL 32901 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 0657 interventions that required staff to cue, supervise, and re-orient him to provide a safe environment. Level of Harm - Minimal harm or potential for actual harm On 6/14/2023 at 11:32 AM, the DON checked resident #21's medical record and acknowledged the last smoking assessment was completed on 11/23/2022 and noted the resident may not smoke unsupervised. She said there were 2 missing assessments since that time and could not explain why they had not been done. Residents Affected - Some On 6/12/2023 at 1:40 PM, the Receptionist was observed sitting at the reception station in the lobby while answering the phone. On 6/12/2023 at 1:41 PM, resident #21 was observed outside in front of the building sitting in a wheelchair at a patio table among 6 other residents. A cigarette lighter was on the table, and there were no staff present. On 6/12/2023 at 1:44 PM, the Receptionist walked out of the building to the outside smoking area. She explained she came from the reception station in the lobby to check on the residents who were outside smoking and she assisted with smoke breaks. On 6/14/2023 at 11:35 AM, the DON said the receptionist kept the schedule for smoke breaks. She stated the receptionist was responsible for answering the phone and she checked residents during smoke breaks. She could not explain how the receptionist managed both tasks and ensured smoking safety. She explained smoke breaks were expected to always be supervised, and she was aware supervision was not provided in the afternoon on 6/12/2023 for the entirety of the break and could not explain why that happened. The facilities policies and procedures dated 3/02/2019, titled Comprehensive Care Plans, read, . There will be ongoing documentation of the nursing process related to the resident needs from admission to discharge. c. Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. The facilities policies and procedures dated 10/19/2020, titled Resident Smoking and Smokeless Tobacco Use, read, . 8. Residents who smoke will be further evaluated to determine additional safety interventions warranted. , and Safety measures for the designated smoking area will include, but not limited to: f. Staff Supervision . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105671 If continuation sheet Page 7 of 13 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 105671 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at Melbourne Inc 1420 South Oak Street Melbourne, FL 32901 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 0675 Honor each resident's preferences, choices, values and beliefs. 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 implement orthopedic follow up care and services for 1 of 2 residents reviewed for rehabilitation and restorative from a total sample of 35 residents, (#90). Residents Affected - Few Findings: Review of the medical record revealed resident #90 was admitted to the facility on [DATE] from an acute care hospital after a fall resulting in a fracture to his left upper arm. The resident's diagnoses included fracture of left humerus (upper arm), muscle weakness, history of falls, and depression. The Minimum Data Set admission assessment with Assessment Reference Date 6/5/2023 noted the resident scored 10 out of 15 on the Brief Interview for Mental Status which indicated he had moderate cognitive impairment. The assessment showed the resident did not have any behavioral symptoms and did not reject of care or evaluation. The assessment noted the resident required partial to moderate assistance from staff to complete Activities of Daily Living (ADL), had range of motion impairments to the left upper side of his body, and he received Physical Therapy (PT) and Occupational Therapy (OT) for 4 days out of 7 during the look back period. The comprehensive care plan included focus items for assistance with ADLs so the resident will maintain/improve his quality of life with interventions that included having him participate to the fullest extent possible with each interaction, depression with goals to allow him to function to his highest level, discharge plans with the goal to return home, and an noted the resident to remain in the facility on a short term basis as, His focus will be on getting better as opposed to attending activities. The hospital discharge Order Report dated 5/29/2023 scanned into the medical record showed the resident required orthopedic physician follow up care for a fracture to his left upper arm, within 10 to 14 days. The Order Summary Report included physician's orders for the resident to follow up with an orthopedic physician within 10 to 14 days after admission with office contact information, no weight bearing restrictions to the left arm, and use of an immobilizer sling to the left arm at all times. On 6/13/2023 at 8:35 AM, resident #90 was observed in his room sitting on the side of the bed. The resident was wearing an immobilizer sling that secured his left arm. The resident was visibly distressed while explaining he wanted to return home. He explained that therapy had not been working with him on his upper extremities, only his lower extremities to assist him with gaining strength and lower his risk for falling. He said he didn't understand why it was taking so long to start therapy to strengthen his arms. He stated therapists had told him they were waiting for an X-ray. The resident said, I'm working really hard, and that's the only thing keeping me from getting back home. On 6/14/2023 at 5:11 PM, the Therapy Director said the resident had been receiving PT and OT care and services 5 times per week since 5/31/2023. He said resident #90 was very motivated with treatment and they were only able to treat his lower extremities while awaiting physician clearance on his upper extremities. He said he last asked the Director of Nursing about the issue the previous week and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105671 If continuation sheet Page 8 of 13 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 105671 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at Melbourne Inc 1420 South Oak Street Melbourne, FL 32901 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 0675 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few she had told him she would follow up. He said the resident was at risk for increased muscle tightening and contracture with long term use of a sling. He explained the resident was very anxious to return home, and he could have gone home sooner but they weren't able to work on his left arm. He said as soon as they could work on the resident's arm, going home, won't be an issue. Review of the North Unit Appointment Binder kept at the nurses station did not show an upcoming orthopedic appointment was scheduled for resident #90. On 6/14/2023 at 12:19 PM, the acting North Unit Manager explained that when residents were admitted from the hospital with orders for follow up appointments, nurses provided the Staffing Coordinator/Appointment Scheduler with a copy of the order to set up an appointment and arrange transportation. She checked the Unit Appointment Binder and said it contained all appointments up to the June 2023 calendar page that were scheduled to date. On 6/14/2023 at 1:04 PM, the Staffing Coordinator/Appointment Scheduler said she was not provided information for resident #90 to set up an orthopedic follow up appointment and transportation. She said she was not aware the resident still needed an appointment. On 6/14/2023 at 1:13 PM, the Director of Nursing checked resident #90's medical record and acknowledged there were orders for the resident to follow up with an orthopedic physician by 6/13/2023, and she noted the resident didn't even have an appointment yet. She said the appointment should have been made within the first few days after the resident was admitted to ensure he was seen within the timeframe of the physican's orders. She could not explain how the appointment was missed. The facilities undated policy and procedure titled, Appointments Process read, DESK NURSE and Unit Managers/Supervisors to check binder daily to schedule any appointments that have not already been scheduled to allow for adequate time to set up transportation. NOTE: Some insurances require a week's notice for transportation therefore appointments should be scheduled at least (a) week out to allow for appropriate scheduling . The Facility assessment dated [DATE] page 10, read, Activities of Daily Living . and Mobility with fall/fall with injury prevention . supporting resident independence in doing as much of these activities by himself/herself. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105671 If continuation sheet Page 9 of 13 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 105671 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at Melbourne Inc 1420 South Oak Street Melbourne, FL 32901 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 0694 Provide for the safe, appropriate administration of IV fluids 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 provide intravenous (IV) care and services according to standards of practice and plan of care for 1 of 1 resident reviewed for IV care out of total 35 sampled residents, (#445). Residents Affected - Few Findings: Resident # 445's medical record revealed he was initially admitted to the facility on [DATE] with diagnoses to include osteomyelitis, sepsis, and acute kidney failure. Review of the Minimum Data Set (MDS) Modification of admission assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 03 out of 15 which indicated resident #445 had severe cognitive impairment. Review of the medical record for resident #445 revealed physician orders dated 6/02/23 that read, PICC (Peripherally Inserted Central Catheter) Midline right arm, monitor for signs and symptoms of infection, swelling, color change, pain, drainage every shift and as needed (PRN). If present notify physician. An additional order dated 6/02/23 read, PICC Midline change dressing every 7 days and PRN using sterile technique. A PICC line is a long, thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart . A PICC line gives your doctor access to the large central veins near the heart. It's generally used to give medications . A PICC line requires careful care and monitoring for complications, including infection and blood clots (retrieved on 6/16/23 from www.mayoclinic.org). On 6/12/23 at 12:30 PM, resident #445 was observed at his bedside in a wheelchair. The resident had an upper right arm PICC line with a clean clear dressing dated 5/30/23. The resident stated he had received antibiotics through the line but the dressing had not been changed. On 6/12/23 at 4:30 PM, Licensed Practical Nurse (LPN) A reported IV intermittent line dressing changes were to be done either every 3 or 7 days. LPN A acknowledged #445's PICC line dressing was dated 5/30/23, 14 days ago and confirmed she had not changed the dressing. On 6/15/23 at 5:39 PM, the Director of Nursing explained her expectation was for the nurses to follow physician orders. She acknowledged dressings for PICC lines should be changed every 7 days or as needed. Review of the facility policy and procedure, Infection Control-Central Venous Catheter/Center Line Access and Maintenance Issued 3/2/19, revised 3/2/19 revealed the following: Dressings that are wet, soiled or dislodged should be replaced using aseptic technique with sterile or clean gloves. Otherwise, transparent dressings are changed every seven (7) days and sterile gauze dressings are changed every two (2) days. Review of the Policy and Procedure for Physician Services issued 3/02/19 read: All physician orders will be followed as prescribed and if not followed, the reasons shall be record on the resident's medical record during that shift. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105671 If continuation sheet Page 10 of 13 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 105671 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at Melbourne Inc 1420 South Oak Street Melbourne, FL 32901 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to honor resident preferences and follow dietary orders for 1 of 3 residents reviewed for food concerns from a total sample of 35 residents, (#23). Findings: Resident #23 was admitted to the facility from the hospital on 4/21/23 for therapy and nursing services. His admission diagnoses included a recent laparoscopic cholecystectomy (gallbaldder removal) procedure, diabetes mellitus, anxiety, and depression. On 6/12/23 at 12:35 PM, resident #23 said he had gallbladder removal surgery and was told this morning at breakfast that staff on the unit told him they no longer have 2% milk for his cereal. He reported he had requested 2% milk as a preference with his cereal because regular milk caused him diarrhea since his gall bladder removal and the 1% milk tasted like water. Review of resident #1's diet order dated 5/11/23 revealed he was to receive a regular textured consistent carbohydrate diet (CCD) diet with thin liquids. The order also included additional food directions which read fortified foods twice a day, fortified mashed potatoes at lunch and fortified soup at dinner for weight stabilization, and [Resident] wants Frosted flakes and 2% milk for breakfast daily, states [he] can tolerate 2% milk. On 6/14/23 at 10:20 AM, observation of the kitchen's walk-in refrigerator with Dietary Aide H revealed three and a-half gallons of 2% milk were in the refrigerator. She stated they always kept 2% milk and didn't know why he was told we didn't have any by the floor staff. On 6/14/23 at 10:30 AM, interview with the Certified Dietary Manager (CDM) verified the kitchen always had 2% milk on hand for the residents. She said they received deliveries twice a week and don't run out. At this time, resident #23's breakfast tray card for 6/14/23 was reviewed with the CDM. It included that he preferred cold cereal, grits, and orange juice for breakfast. There was no mention the resident preferred or wanted 2% milk with his breakfast cereal as indicated on the 5/11/23 order. The CDM acknowledged 2% milk was not listed as a preference on his breakfast card and stated that it should be there so dietary and nursing staff will know what to give him. The nursing to dietary Communication Form dated 5/31/23 was reviewed with the CDM during the above interview. It read, wants frosted flakes & 2% milk daily for breakfast states he can tolerate 2% milk. The CDM said nursing gave her a copy of the communication forms but could not say why the 2% milk was not placed on the breakfast tray card. The CDM acknowledged the [NAME] for resident #23 used by Certified Nursing Assistants (CNAs) did not include information the resident wanted cereal and 2% milk daily for breakfast. Review of resident #23's medical record revealed that a dietary preference assessment had not been completed by the dietary manager. On 6/14/23 at 11:35 AM, the Regional Dietary Manager said the facility's Dietary Manager was on medical leave during the time resident #23's initial food preference assessment came due and the person replacing her did not have access to the facility's electronic medical record system. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105671 If continuation sheet Page 11 of 13 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 105671 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at Melbourne Inc 1420 South Oak Street Melbourne, FL 32901 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 6/14/23 at 1:15 PM, resident #23 said that this morning, the 2% milk for his breakfast cereal was not on his tray and was not offered to him. He had to ask for it. Resident #23's dietary care plans included that he was at nutritional risk related to low albumin levels and skin integrity initiated 5/17/23. Interventions included the following: Provide diet as ordered, adjust as needed for resident food and dining preferences. Adjust meal selections as needed. Observe acceptance of meals, offer alternates as needed. A facility policy and procedure titled, Resident Food Preferences, version 1.3, included the following: Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modifications to diet will only be ordered with the resident's or representative's consent. Upon the resident's admission (or within 72 hours after his/her admission) . will identify a resident's food preferences. When possible staff will interview with resident directly to determine current food preferences based on history and life pattern related to food and mealtimes. Nursing staff will document the resident' food and eating preference in the care plan . If the resident refuses or is unhappy with his or her diet, the staff will create a care plan that the resident is satisfied with. The CDM Charting Quick Reference Guide, revised 7/1/2020, included the following: Meet/Greet [the resident] within 72 hours of admission. Complete the Food Service Preference Data Collection . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105671 If continuation sheet Page 12 of 13 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 105671 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at Melbourne Inc 1420 South Oak Street Melbourne, FL 32901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure proper disposal of sharps in a puncture-resistant sharps container for 1 of 1 resident out of a total sample of 35 (#29). Residents Affected - Few Findings: Resident #29 was readmitted to the facility on [DATE] with a previous admission on [DATE] from the hospital with diagnoses of complete traumatic amputation, oral phase dysphagia, type 2 diabetes, depressive, anxiety disorder, and basal cell carcinoma of the skin. On 6/12/23 at 11:25 AM, after observation of a point of care testing for blood sugar monitoring of insulin administration with Licensed Practical Nurse (LPN) G, the LPN G placed the soiled blood lancet into a water cup, doffed her gloves and placed them inside the same water cup. She then walked over to the trash can next to the sink in resident #29's room and placed the water cup with the soiled blood lancet and doffed gloves into the trash can. Observation revealed a sharps containers readily accessible in front of LPN G to the right of the sink in resident #29's room. She then proceeded to wash her hands and exit the room. On 6/12/23 at 11:30 AM, LPN G acknowledged the soiled lancet was considered a sharp, it is a blood sugar lancet. She confirmed she disposed of the soiled lancet in the trash can and said she was aware it should have been placed in the sharps container. She explained it was her mistake and noted it was her responsibility to make sure the lancet was placed in the sharps container. On 6/14/23 at 10:23 AM, the Director of Nursing (DON) stated the expectation was nurses place sharps inside the sharps container not in a trash can. Review of LPN G's Job description LPN/RN Supervisor dated and signed on 10/5/22 revealed ensure cleanliness and safety of all nursing service treatment areas, and assist in sanitation function in developing implementing and maintaining safety standards. Review facility infection control-Point of Care Devices and Injection Safety revised 3/2/19 showed it is the policy of the facility to ensure that appropriate infection prevention and control measures are taken to prevent the spread of infection in accordance with state and Federal Regulations, and national guidelines. All lancets, finger stick devices, and injection equipment are to be disposed of in an approved sharps container at point of use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105671 If continuation sheet Page 13 of 13