Health inspection·February 14, 2025

F 0554 cognition. Level of Harm - Minimal harm or potential for actual harm On 2/10/25 at 11:21 AM, resident #305 was observed standing next to his bed. The nightstand was observed with a bottle of 300 mg/100 caplets Tylenol 8 hour arthritis pain. The resident stated he keeps the Tylenol at his bedside because he has arthritis pain in the knees. Residents Affected - Few On 2/10/25 at 12:08 PM, the resident's nightstand was observed with (RN) F Primary care nurse. She acknowledged the bottle of 300 mg/100 caplets Tylenol 8 hr arthritis pain. A review of the resident's physician orders with RN F revealed no orders for Tylenol found on the resident's nightstand. The RN explained that for someone to self-administer medications, they must have a physician order and a self-administration evaluation completed. RN F stated there was no order for Tylenol and that the resident did not have a completed medication self-administration evaluation. On 2/12/25 at 2:30 PM, the Director of Nursing (DON) stated residents should not have medications at the bedside to prevent overdose. She also explained a self-administration assessment must be completed to ensure residents could safely self-administer medication. She confirmed residents #49 and #302 were not evaluated for medication self-administration. A review of the facility's policy and procedure for Self-Administration of Medication Program dated 6/26/24 revealed, It is the policy of the facility to allow the resident and or the legal representative of the resident the right to self-administer medications when it has been deemed by the interdisciplinary team that it is clinically appropriate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105671 If continuation sheet Page 2 of 23 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 02/14/2025 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 0558 Reasonably accommodate the needs and preferences of each resident. 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 a call light device was within reach for 1 of 3 residents reviewed for accommodation of needs, of a total sample of 43 residents, (#52). Residents Affected - Few Findings: Review of the medical record revealed resident #52, a [AGE] year old female was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, thyroid disorder, chronic pain syndrome, major depressive disorder, persistent mood disorder, anxiety disorder, dementia, Pseudobulbar Affect (uncontrollable crying/laughing), and cognitive communication deficits. The most recent Minimum Data Set Quarterly Assessment with an Assessment Reference Date of 12/30/24 revealed during the look-back periods, resident #52 had impaired vision, was rarely/never understood, and unable to complete the Brief Interview for Mental Status. Staff assessed the resident had short term and long term memory problems, was severely cognitively impaired, had continuous inattention and disorganized thinking that did not fluctuate, delusions, and was dependent on staff to complete all Activities of Daily Living (ADL). The resident did not walk, required a wheelchair, was always incontinent of bladder and bowel functions, required scheduled and as needed pain medication, a mechanically altered diet, and received high-risk anti-depressant and opioid medications. The Order Summary Report included active physician's medication orders for Donepezil (enzyme blocker) 10 Milligrams (MG) at bedtime for dementia, Levothyroxine (thyroid hormone) 112 Micrograms once daily for thyroid disorder, Nuedexta (central nervous system agent) 20-10 MG every twelve hours for Pseudobulbar Affect, Tramadol (opioid pain) 50 MG three times daily for chronic pain, and Trazodone (anti-depressant) 25 MG at bedtime for depression. The Comprehensive Care Plan included focuses for diabetes mellitus, thyroid disorder, incontinence, risk for skin breakdown, impaired communication and hearing, risk for falls, dementia with behaviors, high-risk medication adverse effects monitoring, squamous cell cancer, required staff assistance for all ADLs, and Long Term Care (LTC) with a goal to assure maintenance of the resident's safety and comfort, and observance of distress. On 2/10/25 at 10:45 AM and 3:56 PM, resident #52 was observed in her room awake and lying in bed. The call light cord with a squeeze bulb activator was lying on the floor under the resident's bed on the left side. On 2/11/25 at 3:12 PM, the resident's door was closed; the call light cord and bulb were observed on the floor in the same location. On 2/11/25 at 3:40 PM, Certified Nursing Assistant (CNA) J said she knew resident #52 well, as she was often included in her assignment. The CNA explained the resident was able to use her hand and arms to activate a call light bulb. In a joint observation on 2/11/25 at 3:43 PM, CNA J and Licensed Practical Nurse (LPN) K observed resident #52's call light cord and squeezable bulb lying on the floor under the bed. LPN K picked up the device and clipped it to the resident's bed sheet so the bulb was within reach of the resident's hand. LPN K explained, staff were expected to check and make sure the device was within reach so the resident could use it if needed. The LPN said when the room door was closed, staff were unable to hear her yell out and confirmed the call light shouldn't be on the floor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105671 If continuation sheet Page 3 of 23 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 02/14/2025 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 2/11/25 at 3:55 PM, the Unit Manager explained she expected staff to check residents' call lights and ensure they were safely within reach every time before they exited a room. She said CNAs typically checked on bedbound residents every two hours for incontinence care and repositioning and stated, they shouldn't leave the room with a call light on the floor. Review of the Facility assessment dated [DATE] noted the facility provided person-centered care for persons with dementia, staff responded to residents' requests for assistance promptly in order to promote resident dignity, and staff training and competency included resident call lights. Event ID: Facility ID: 105671 If continuation sheet Page 4 of 23 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 02/14/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, and interview, the facility failed to provide a homelike environment for residents who ate in the dining rooms on the two (North and South) nursing units. This affected all residents who chose to eat in the nursing unit's dining areas, which varied from approximately 8-20 residents per meal of the 98 residents at the facility. Findings: On 2/10/25 at 12:35 PM, four staff were observed serving trays to residents on the North unit from the food cart. There were seven residents sitting at tables in the North unit dining room waiting to be served. There were no tablecloths or centerpieces on the tables and the dishes were left on the serving trays. On 2/10/25 at 1:38 PM, lunch was provided to approximately thirteen residents in the South unit dining room. There were no tablecloths or centerpieces on the tables. All the dishes, flatware, cups and food items were left on the resident's trays while they ate. On 2/10/25 at 5:59 PM, residents were observed eating in the South unit room dining room from their trays. The undecorated tables held newspapers and pieces of paper with word puzzles on them that had been used earlier in the day. On 2/11/25 at 1:18 PM, during the lunch service on the South and North unit's dining rooms the residents ate from their trays on undecorated tables as they did the previous day. On 2/12/25 at 5:21 PM, resident #77 described the dining area felt like a cafeteria, and could be made nicer with tablecloths or decorations. On 2/12/25 at 10:28 AM, the Registered Dietetic Technician (DTR) stated she thought everyone would enjoy a little more decoration in the dining room, like centerpieces in the area in which they dine. On 2/13/25 at 1:10 PM, the Administrator observed all residents in the South unit dining room ate from trays. She acknowledged that serving all residents on trays could be considered a dignity issue because it was more institutional, than home-like. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105671 If continuation sheet Page 5 of 23 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 02/14/2025 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 observation, interview, and record review, the facility failed to complete a new Preadmission Screening and Resident Review (PASSAR) level I screen to ensure additional mental health services were not required for 1 of 5 residents reviewed for PASSAR, of a total sample of 43 residents, (#62). Findings: Resident #62 was admitted to the facility on [DATE] with diagnoses that included dementia, cognitive communication disorder, generalized anxiety disorder, and insomnia. Other diagnoses were added later and included Schizophreniform disorder on 9/14/23, persistent mood disorder on 10/02/23, and major depressive disorder on 8/01/24. Resident #62's Quarterly Minimum Data Set assessment dated [DATE], revealed he was severely cognitively impaired and required substantial to maximum assistance for activities of daily living. Review of resident #62's medical record revealed a PASSAR Level I had been completed on 8/08/23 with diagnosis of anxiety disorder listed. The facility could not provide evidence of a new screening. Review of psychiatric note dated 2/10/25, revealed that resident #62 was being treated for depression, anxiety, dementia, insomnia, mood disorder, and schizophreniform disorder. The Psychiatric consult noted that the resident had exhibited behaviors such as auditory hallucinations and sleeping issues. On 2/14/25 at 2:00 PM, the Director of Nursing (DON) jointly with the Regional Director of Clinical Services said she was not aware resident #62 had a new diagnosis that required a new PASSAR screen. The Regional Director of Clinical Services said she assisted the DON with PASSARs but was unaware a new screening was required for resident #62 after the new diagnoses. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105671 If continuation sheet Page 6 of 23 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 02/14/2025 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 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 observation, interview, and record review, facility failed to ensure nurses followed physician's orders to monitor fingerstick blood glucose for 1 of 1 resident reviewed for change of condition, of a total sample of 43 residents, (#93). Residents Affected - Few Findings: Review of the medical record revealed resident #93, a [AGE] year old male was admitted to the facility from an acute care hospital on [DATE] with diagnoses that included, hemiplegia and hemiparesis (partial paralysis), generalized anxiety disorder, dysphagia (difficulty swallowing), hypertension (high blood pressure), gastrostomy (feeding tube) status, atrial fibrillation (abnormal heart rhythm), encephalopathy (brain dysfunction), stroke, and diabetes mellitus. The most recent Minimum Data Set 5-day Assessment with an Assessment Reference Date of 11/26/24 noted during the look-back periods, resident #93 had difficulty swallowing, required a feeding tube for nutrition and hydration, received insulin injections for 7 out of 7 days, and high risk antipsychotic, antianxiety, antidepressant, anticoagulant (blood thinner), and hypoglycemic (blood sugar lowering) medications. The Order Summary Report noted active physician's medication orders included Diabetisource AC (before meals) enteral (feeding tube) formula 60 milliliters per hour from 8:00 PM to 6:00 AM, Carvedilol 6.25 Milligrams (MG) twice daily for hypertension, Doxazosin Mesylate 1 MG at bedtime for hypertension, Glargine Insulin 45 Units (U) twice daily for diabetes, Lispro Insulin 4 U four times daily for diabetes, and Lispro Insulin, dosage per sliding scale finger stick blood sugar results before meals for diabetes. The Comprehensive Care Plan included focuses for diabetes mellitus with interventions for nurse monitoring of blood glucose and risk of complications, and dependence on enteral feeding for nutrition with interventions for nurse monitoring of functioning/maintenance and risk of complications. During a medication administration observation on 2/10/25 at 11:32 AM, Licensed Practical Nurse (LPN) E collected resident #93's finger stick blood sugar with a result of 175 milligrams per deciliter (mg/dl). The nurse said physician's orders were to give the resident an extra 2 units of Lispro insulin. She explained, she was unable to locate resident #93's Lispro insulin in the medication cart. The nurse explained the facility's on hand emergency medication kit did not contain Lispro. At 12:04 PM, LPN E said she contacted the physician and obtained orders to hold the Lispro and re-check resident #93's blood glucose every hour until the refill arrived from the pharmacy. Review of a nurse progress note completed by LPN E on 2/10/25 at 12:17 PM, read, insulin unavailable at the moment awaiting pharmacy to deliver STAT [immediately/urgently] MD [physician] notified and said to keep checking bs [blood sugar] once every hour until insulin gets here. On 2/10/25 at 3:25 PM, LPN L said LPN E had left for the day and she received off-going report from her. The nurse said LPN E had not mentioned resident #93 was out of insulin nor that the doctor had given orders to check his blood glucose every hour until the refill arrived. Review of the Weights and Vitals Summary Report noted a struck-out entry by LPN L on 2/10/25 at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105671 If continuation sheet Page 7 of 23 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 02/14/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 3:31 PM, of a finger stick blood sugar measurement of 157 mg/dl and an additional measurement of 137 mg/dl at 4:30 PM. On 2/12/25 at 10:47 AM, LPN E recalled on 2/10/25 at lunchtime, she obtained doctor's orders to re-check resident #93's blood sugar once an hour. She said she completed re-checks every hour until the end of her shift at 3:00 PM and stated, it was in a good range. On 2/12/25 at 12:46 PM, the Unit Manager recalled on 2/10/25, LPN E obtained a doctors order to hold resident #93's lunchtime insulin and re-check the blood sugar until the insulin was delivered because it wasn't in the emergency medication kit. The Unit Manager checked the medical record and was unable to locate any re-checks by LPN E on 2/10/25. She acknowledged there were no re-checks until LPN L's was recorded at 4:30 PM, four hours after LPN E received physician's orders. The nurse stated, she didn't check it every hour per the MD [physician] order; it's important for them to re-check, especially if it was a brittle person. On 2/14/25 at 10:13 AM, the Director of Nursing (DON) explained nurses were expected to follow doctor's orders and monitor residents for abnormal blood glucose to prevent re-hospitalization and complications. The DON stated, the nurse should have monitored the resident. Review of the facility's standards and guidelines titled Change in Condition Process dated 3/02/19 noted nurses were expected to evaluate the resident's status and document findings in the electronic medical record. The Facility Assessment noted the facility provided nursing services and care including management of medication and medical conditions including diabetes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105671 If continuation sheet Page 8 of 23 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 02/14/2025 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 0692 Provide enough food/fluids to maintain a resident's health. 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 monitor identified weight loss and impaired nutrition risk for 2 residents (#52, #15); and failed to properly monitor the clinical condition for 1 resident, (#34), out of 7 residents reviewed for nutrition, of a total sample of 43 residents. Residents Affected - Few Findings: 1. Review of the medical record revealed resident #52, a [AGE] year old female was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, thyroid disorder, chronic pain syndrome, major depressive disorder, persistent mood disorder, anxiety disorder, dementia, Pseudobulbar Affect (uncontrollable crying/laughing), and cognitive communication deficits. The most recent Minimum Data Set (MDS) Quarterly Assessment with an Assessment Reference Date (ARD) of 12/30/24 revealed during the look-back periods, resident #52 had impaired vision, was rarely/never understood, and unable to complete the Brief Interview for Mental Status (BIMS). Staff assessed the resident had short term and long term memory problems, was severely cognitively impaired, had continuous inattention and disorganized thinking that did not fluctuate, delusions, and she was dependent on staff to complete all Activities of Daily Living (ADL). The resident did not walk, required a wheelchair, had no weight loss or gain, required scheduled and as needed pain medication, a mechanically altered diet, and she received high-risk anti-depressant and opioid medications. The Order Summary Report included active physician's orders for monthly weights. Medication orders included Donepezil (enzyme blocker) 10 Milligrams (MG) at bedtime for dementia, Levothyroxine (thyroid hormone) 112 Micrograms once daily for thyroid disorder, Nuedexta (central nervous system agent) 20-10 MG every twelve hours for Pseudobulbar Affect, Tramadol (opioid pain) 50 MG three times daily for chronic pain, and Trazodone (anti-depressant) 25 MG at bedtime for depression. The Comprehensive Care Plan included focuses for diabetes mellitus, thyroid disorder, incontinence, risk for skin breakdown, impaired communication and hearing, risk for falls, dementia with behaviors, high-risk medication adverse effects monitoring, squamous cell cancer, required staff assistance for all ADLs, and Long Term Care (LTC) with a goal to assure maintenance of the resident's safety and comfort, and observance of distress. On 2/11/25 at 10:45 AM, resident #52 was observed awake and lying in bed in her room. The resident did not answer questions and was unable to participate in an interview. On 2/11/25 at 3:43 PM, Certified Nursing Assistant (CNA) J said resident #52 was often included in her assignment, required staff assistance to eat, and needed cues and reminders to ensure she was eating enough. Review of the Dietary Progress Note dated 10/03/24 noted resident #52 was evaluated for weight loss, insufficient intake, and a low Body Mass Index (BMI). Orders for calorically dense supplements twice daily between meals and fortified foods were implemented for weight loss and low BMI. The Weights and Vitals Report showed on 9/12/24, resident #52 had a 8.7% or 11 pound weight loss over two months. Additional weights were not completed after 11/07/24, for three months. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105671 If continuation sheet Page 9 of 23 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 02/14/2025 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In a joint interview with the Dietary Technician (DT) and Registered Dietician (RD) on 2/12/25 at 12:09 PM, the DT said she visited the facility once weekly to complete evaluations for new admissions and concerns when she was informed by nursing. She said weight loss was tracked from a facility provided report and was acted on for identified weight loss. She explained that typically, nutritional supplements were added to help avoid nutritional complications of weight loss and weights were often re-checked more frequently with weight loss in vulnerable, aging residents. On 2/12/25 at 1:56 PM, the Unit Manager said all residents were weighed on admission, and at least monthly and it was assigned by the Director of Nursing (DON). She explained the facility's Dietician monitored residents for any weight loss concerns. In a joint interview with the DT, RD, and DON, the DT checked resident #52's medical record and said the last progress note dated 10/03/24 showed the resident triggered for significant weight loss. She said orders were added for Med Pass (supplement) and fortified foods. She checked the medical record and said no weights had been completed for the resident since 11/07/24, so she was not aware of the resident's status since that time. The RD stated, weight maintenance is important because it affects wound healing and optimal health and well-being. 2. Review of the medical record revealed resident #15, a [AGE] year old female was admitted to the facility on [DATE] with diagnoses that included Multiple Sclerosis, osteoarthritis, dementia, pulmonary embolism (blood clot of lung), major depressive disorder, seizures, muscle weakness, and vitamin D deficiency. The most recent MDS Quarterly Assessment with an ARD of 11/29/24 revealed during the look-back periods, resident #15 scored 1 out of 15 on the BIMS which indicated she was severely cognitively impaired. The assessment showed the resident had range of motion functional limitations in both upper extremities (shoulder, elbow, wrist, hand), and she was fully dependent on staff to complete all ADLs, including eating. The resident did not walk, required a wheelchair, had no weight loss or gain, and she received high-risk anti-coagulant (blood thinner) and anti-convulsant (seizure) medications. The Care Plan Report included focuses for staff dependence to complete all ADLs including eating related to limitations in both shoulders with a goal to receive assistance necessary to improve/maintain quality of life, and an intervention for physician notifications for significant intake changes. Additional focuses included, incontinence, risk for skin breakdown, depression and anxiety, risk for falls, impaired cognition and thought processes/memory loss, high-risk medication adverse effects monitoring, multiple sclerosis with interventions to monitor diet and intake, missing natural teeth, expected LTC needs due to limitations with a goal to assure maintenance of the resident's safety and comfort, and observance of distress and nutritional problems related to chronic conditions, varied intake, and vitamin deficiency with an intervention for the RD to evaluate, monitor, and make recommendations. On 2/11/25 at 9:22 AM, resident #15 was observed in her room lying in bed. She did not respond to questions and her uneaten breakfast tray was observed on the bedside table. On 2/11/25 at 3:43 PM, Licensed Practical Nurse (LPN) K said resident #15 required staff assistance to eat her meals. The nurse said the resident was confused and was dependent on staff to make sure she ate enough. Review of the Weights and Vitals Summary noted the resident was weighed on 9/12/24, 10/02/24, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105671 If continuation sheet Page 10 of 23 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 02/14/2025 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 0692 Level of Harm - Minimal harm or potential for actual harm 10/03/24, 10/04/24, and 11/07/24. In two months, the resident had a weight loss of 5.6 pounds. The resident was not weighed again until 2/07/25, for three months and showed a weight loss of 18.8 pounds or 12.6%. Since the resident was admitted to the facility, she had a total weight loss of 24.4 pounds, or 15.8%, over 5 months. Residents Affected - Few Active physician's orders included monthly weights. The Nutrition Comprehensive Evaluation/Risk Screen dated 9/05/24 noted resident #15 had abnormal nutrition related labs, other risk factors, a low Body Mass Index (BMI), and she was at nutritional risk. The dietician recommended increased larger protein portions at breakfast to meet nutritional needs. A Dietician progress note dated 2/12/25 showed resident #15 was re-evaluated for significant weight loss over 90 days with recommendations to increase protein portions for all three meals. In a joint interview with the DT, RD, and DON on 2/12/25 at 2:05 PM, the DT said she completed a comprehensive nutritional assessment for resident #15 when she was admitted in September 2024 that showed some nutritional risks, so she recommended additional protein intake at breakfast. She explained the facility did not report any weight loss in the monthly reports she received until 2/07/25 and a re-evaluation was completed on 2/12/25 for significant weight loss. The Dietary Technician explained, resident #15's weight loss wasn't reported for three months because the medical record showed the resident wasn't weighed and a re-evaluation would have been completed if the facility had reported it. She checked the medical record and confirmed resident #15 triggered for weight loss and required another assessment and possibly additional interventions. On 2/12/25 at 2:15 PM, the DON said the facility's policy was to weigh all residents at least monthly by the 8th of every month, and more frequently when needed. She explained reports were generated monthly and CNAs completed weights for all residents due, as directed by the DON. The DON said she could not explain why there were no monthly resident weights completed between November 2024 and February 2025 and stated, it's important to get weights to make sure they're not losing weight, to maintain nutrition and monitor underlying medical conditions or comorbidities that may affect their health and well-being. Review of the facilities standards and guidelines titled Weight Management and dated 3/22/19 noted all residents were weighed at least every month, monitored by Dietary, and re-weights were obtained for any gain or loss of 5 pounds from the previous weight. 3. Resident #34 was admitted to the facility on [DATE] with diagnoses which included End Stage Renal Disease (ESRD) with dependence on renal dialysis, chronic pain syndrome, secondary malignant neoplasm of breast, gout, dementia without behavioral disturbance, and primary insomnia. The admission Evaluation completed on 1/13/25 indicated the resident's initial weight was 00000 (not taken). This evaluation also indicated the resident's skin had some redness but was intact without any skin breakdown, and had no issues with her appetite. Resident #34's care plan indicated she had a Stage IV pressure ulcer on her coccyx with interventions to monitor nutritional status and obtain weekly skin checks, document, and notify Medical Doctor (MD) of any changes in skin integrity (initiated 1/14/25). The Care Plan also indicated this resident had nutritional problem related to cancer, dementia, dialysis, therapeutic diet, and varied oral intake with a goal of resident tolerating diet and not having significant weight loss through review (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105671 If continuation sheet Page 11 of 23 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 02/14/2025 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 0692 date. One of the interventions was to provide and serve supplements as ordered (initiated 1/16/25). Level of Harm - Minimal harm or potential for actual harm The Nutrition Comprehensive Evaluation dated 1/16/25 indicated resident #34's food intake varied between 25-100% of meals and was inadequate to meet her needs which were estimated to be between 2400-2800 calories and 96-112 grams protein/day. The nutritional assessment indicated the resident did not have any skin issues/ pressure ulcers which was obtained from the resident's nursing admission assessment. This was in conflict with the care plan which indicated the stage IV pressure ulcer upon admission. The assessment indicated her current body weight was 80.27 kilograms (kg) or 176.59 pounds (lbs.) from the weight recorded during her recent hospital stay, the resident reported her appetite was diminished and she was not interested in the food being served. A recommendation for one Nepro oral nutritional supplement was made due to varied food intake and dialysis. Residents Affected - Few Resident #34's medical record revealed a physician order dated 1/14/25, which indicated nurses were to complete a weekly skin observation every night shift on every Wednesday. The Weekly Skin Observation nursing reports dated 1/16, 1/30, and 2/05/25 all indicated the resident had no old or new skin conditions. On 2/11/25 at 9:23 AM, resident #34 stated she had a wound on her backside that hurt. On 2/12/25 at 10:28 AM, the DTR stated the initial admission weight used by the facility for the nutritional assessment was from a prior hospital admission because there was no initial weight obtained when resident was admitted to the facility. She acknowledged that use of a weight measurement completed by another facility was not best practice for assessments or for projected weight change in the future. The DTR stated obtaining an initial weight at the facility was important. She stated she routinely emailed recommendations to nursing to obtain initial weights if they were missing from a resident's record, but confirmed she had not requested one for resident #34 to be weighed. The DTR verified she forgot to put in the order for the nutrition supplement she had recommended, which she acknowledged was her responsibility. She indicated her email to nursing should also have indicated the start of Nepro daily for varied food intake on dialysis. The DTR confirmed that no food preferences were obtained to assist the resident to improve her food intake through alternative meal choices and trying to mimic the meals the resident normally liked to eat. At that time, the Regional Director of Clinical Services (Regional Nurse) reviewed the resident's Head and Toe Initial Assessment which she confirmed did not contain an initial weight upon admission. On 2/14/25 at 9:30 AM, the Regional Nurse stated when nursing identified a weight loss or skin breakdown, they would make the RD or DTR aware through emails. She added after the RD/DTR assessed a resident and decided on supplements, they sent their recommendations to nursing via email. The RD/DTR would keep that resident on their caseload and follow them until their issues were resolved. She added the physician oversaw the RD/DTR recommendations and orders and decided whether they were appropriate or not. The Regional Nurse was not able to provide email communication from nursing to the RD/DTR that made them aware of skin breakdown for resident #34. The RD/DTR Progress Note dated 2/13/25 reported resident #34's weight at 69.4 kg or 152.68 lbs., which was a 23.91 lb. weight difference, and a 13% weight loss from her weight reported during the initial nutrition assessment on 1/16/25, one month prior. This significant weight loss could not be verified as accurate since the initial weight used was taken from a different facility's record, but it did reinforce the high risk nature of this resident's nutritional status, and the importance for obtaining an initial weight for each resident upon admission. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105671 If continuation sheet Page 12 of 23 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 02/14/2025 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 0692 Level of Harm - Minimal harm or potential for actual harm The facility's policy entitled, Weight Management, dated 3/2/19 indicated all residents admitted to the facility would be weighed upon admission and dietary staff would evaluate all weights each month. The policy described the facility would attempt to obtain weights at the same time of the day, preferably in the morning, and with the same scale to ensure accuracy and that the physician and resident or resident's representative would be notified by the nurse of any significant unexpected or unplanned weight changes. Residents Affected - Few The facility's policy entitled, Food and Nutritional Services, dated 3/2/19 indicated the facility would ensure facility staff supported the nutritional well-being of the residents while respecting their right to make choices about his or her diet. In addition the facility would employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of food and nutrition services, taking into consideration resident assessments, individual plans of care and the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment. A member of the Food and Nutrition Services staff must also participate on the Interdisciplinary team. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105671 If continuation sheet Page 13 of 23 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 02/14/2025 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 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 provide emergency equipment available for accidental extubation for a resident on mechanical ventilation with a tracheostomy (trach) per nursing standards of practice for 1 of 1 residents reviewed for tracheostomy, of a total sample of 40 residents, (#22). Residents Affected - Few Findings: Resident #22 was initially admitted on [DATE] and re-admitted on [DATE] with diagnoses which included chronic respiratory failure with hypoxia (low oxygen), anoxic brain damage, dysphagia (trouble swallowing), hypertensive heart disease, and tracheostomy status. A tracheostomy (also called a tracheotomy) is an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs. After creating the tracheostomy opening in the neck, surgeons insert a tube through it to provide an airway and to remove secretions from the lungs. The person with a tracheotomy breathes through the tracheostomy tube (trach tube or obturator) rather than through the nose and mouth. An extubation (when the trach tube is displaced) creates an emergency that requires an obturator be readily available and staff are knowledgeable to reinsert it, (retrieved on 2/16/25 from www.hopkinsmedicine.org). On 2/13/25 at 10:09 AM, resident #22 was observed in bed, calm, and awake with oxygen tubing connected to the oxygen concentrator. The oxygen tubing and the suction tip which was bedside were undated. A bag valve mask (BVM) or Ambu bag was in a clear plastic bag on the wall directly over the head of the resident's bed, but there was no emergency trach kit in the clear plastic bag nor at the bedside. The assigned Licensed Practical Nurse (LPN) G was in resident #22's room at that time and validated the observations. LPN G stated it was the night shift nurses' responsibility to change and date the oxygen tubing along with the suction tip but she did not know how often the tubing needed to be changed. LPN G explained she thought the night shift set up the equipment. She explained she knew how to perform trach care and suction the resident, but was unsure about what to do if there was an emergency and was unaware of the need for an emergency trach kit at bedside. LPN G was unsure who was responsible for the emergency trach supplies at bedside but felt it was possibly Central Supply. A review of the resident #22's medical record revealed physician orders for trach care to be done every day and as needed, oxygen mask tubing /humidifier mask to be changed every week, on night shift every Friday. The physician's orders did not contain an order for emergency supplies including replacement obturator needed for resident #22. A review of the resident's Care Plan identified the resident had a tracheostomy but did not contain interventions for emergency supplies at bedside. On 2/13/25 at approximately 10:45 AM, the Unit Manager (UM), Central Supply staff and a Regional Nurse were in resident #22's room and verified there was no emergency trach kit at the bedside. The Central Supply staff confirmed it was her responsibility to place the emergency trach kit at the bedside. The UM confirmed that emergency trach supplies were supposed to be at bedside and said, this is not what is done here, [she was] not sure what happened . On 2/13/25 at 1:47 PM, the UM said she helped with the education of staff and participated in in-services because the facility did not have a Staff Educator. She verified the importance of having the emergency kit at bedside for residents with a tracheostomy and stated the assigned nurse LPN G (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105671 If continuation sheet Page 14 of 23 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 02/14/2025 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few could get nervous at times but thought she knew what to do in an emergency. The UM explained that the Director of Nursing (DON) was responsible for staff orientation after hire. On 2/13/25 at 1:51 PM, LPN H said that she had worked with resident #22 and knew the importance of having the emergency kit at bedside because, if [the tube] accidentally dislodged they can use items in kit to replace the trach. She explained at least once a shift she should ensure that the emergency supplies were at bedside. On 2/13/25 at 2:16 PM, the DON who was working on the floor because of a nurse call out, explained the training process for new staff nurses. She said upon hire; she would go over the facility's policy then place the new nurse with a preceptor. She explained that new staff were oriented depending on how experienced they were, she would get feedback from the preceptor and proceed accordingly. The preceptor was responsible for showing the orientee most tasks and would have referred to her if they were not comfortable with something. The DON stated she had a plan to do an in-service on trach care because one nurse reached out to her specifically. On 2/14/25 at 11:51 AM, the DON stated the expectation was for the nurses to have verified that resident #22 had an emergency kit at the bedside in case of an accidental dislodgement. The Facility's Policy and Procedure for Respiratory/ Tracheostomy Care and Suctioning revised 3/26/21 indicated, the facility will ensure that residents who need respiratory care, including tracheostomy care and tracheal suctioning is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan and resident goals and preferences. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105671 If continuation sheet Page 15 of 23 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 02/14/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain insulin medications timely for 1 of 26 residents reviewed for medication administration, of a total sample of 43 residents, (#93). Findings: Review of the medical record revealed resident #93, a [AGE] year old male was admitted to the facility from an acute care hospital on [DATE] with diagnoses that included unspecified fall, generalized anxiety disorder, dysphagia (difficulty swallowing), high blood pressure, gastrostomy (feeding tube) status, atrial fibrillation (abnormal heart rhythm), encephalopathy (brain dysfunction), stroke, and diabetes mellitus. The most recent Minimum Data Set 5-day Assessment with an Assessment Reference Date of 11/26/24 noted during the look-back periods, resident #93 had difficulty swallowing, required a feeding tube for nutrition and hydration, received insulin injections for 7 out of 7 days, and high risk antipsychotic, antianxiety, antidepressant, anticoagulant (blood thinner), opioid, hypoglycemic (blood sugar lowering), and anticonvulsant (seizure) medications. The Order Summary Report noted active physician's medication orders included Diabetisource AC enteral (feeding tube) formula 60 milliliters per hour from 8:00 PM to 6:00 AM, Glargine Insulin 45 Units (U) twice daily for diabetes, Lispro Insulin 4 U four times daily for diabetes, and Lispro Insulin, dosage per sliding scale finger stick blood sugar results before meals for diabetes. The Comprehensive Care Plan included focuses for diabetes mellitus with interventions for nurse monitoring of blood glucose and risk of complications. On 2/10/25 at 11:32 AM, Licensed Practical Nurse (LPN) E was observed obtaining a fingerstick blood glucose level from resident #93. She said the resident required 2 U of Lispro insulin per physician's orders. She checked the medication cart and said the resident didn't have any Lispro insulin. She then left to check the facility's emergency medication kit. At 12:17 PM, LPN E explained the emergency kit did not contain Lispro insulin. She said she called the physician who said none of the emergency medications on hand could be used as an alternate, so an order was placed with the pharmacy for delivery expected later that afternoon. LPN E said the physician wanted hourly fingersticks until the insulin arrived. On 2/10/25 at 3:25 PM, LPN L said LPN E had left for the day and she received oncoming report for the 3:00 PM to 11:00 PM shift. The nurse explained that LPN E had not mentioned resident #93 was out of Lispro insulin and the afternoon pharmacy delivery had not arrived yet. On 2/12/25 at 12:46 PM, the Unit Manager recalled on 2/10/25, LPN E asked her to assist with locating Lispro insulin for resident #93 because he didn't have any, and there was none in the emergency kit. She explained medication re-orders were a simple electronic process and nurses were expected to ensure adequate insulin was available. She said nurses should have ordered the insulin when it was low before it ran out. The Unit Manager conveyed resident's insulin was very important to keep on hand, especially for brittle diabetics to ensure treatment interventions were available at the facility to avoid possible re-hospitalization and stated, it must've not been ordered on time. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105671 If continuation sheet Page 16 of 23 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 02/14/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 2/14/25 at 10:13 AM, the Director of Nursing (DON) explained she expected nurses to re-order medications from the pharmacy before the supply was depleted to ensure timely delivery. She conveyed insulin supplies were important to maintain so nurses could administer doses if needed to avoid possible serious complications. The DON did not explain why resident #93's insulin supply was not ordered timely. Review of the facility's standards and guidelines titled Reordering, Changing, and Discontinuing Medication Orders dated 7/01/24 noted medication reorders could be made electronically, in writing, by phone, or facsimile. Review of the facility's standards and guidelines titled Medication Shortages/Unavailable Medications dated 8/01/24 noted when insufficient medication supplies were observed, nurses were expected to immediately reorder from the pharmacy to ensure receipt by the next scheduled delivery and obtain it from the Emergency Medication Supply and/or arrange for an emergency delivery. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105671 If continuation sheet Page 17 of 23 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 02/14/2025 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 - Many 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 provide food to accommodate residents' preferences for 4 of 43 sampled residents, (#77, #403, #34, and #59). Findings: 1. Resident #77 was admitted to the facility on [DATE] with the diagnoses of right tibia fracture, muscle weakness, major depressive disorder, and chronic lung disease. Her physician orders revealed a regular diet was prescribed. On 2/11/25 at 9:01 AM, resident #77 stated she was not going to eat her breakfast of a small donut and sausage because she considered these foods to be unhealthy. She added she had been at the facility for three months and was not aware she could request menu items for her meals. Resident #77 explained she had just found out she could eat outside of her room after she had wandered around one morning about a month after she had arrived. She stated no one had asked her what foods she liked to eat or what foods she disliked. On 2/12/25 at 11:16 AM, the Dietetic Technician, Registered (DTR) reviewed the nutrition assessment completed for resident #77 on 1/02/25. The DTR confirmed the assessment indicated resident #77 was eating well and met her nutritional needs. The assessment did not included any information about the resident's food preferences. The DTR stated if there was not an issue with a resident's intake, she did not discuss food preferences with the residents. 2. Resident #403 was admitted on [DATE] with diagnoses of a crushing injury to his right hand, pain in right hand, cellulitis of upper right extremity, and adjustment disorder with mixed anxiety and depressed mood. His physician orders for February 2025 included a regular diet. Review of the nutrition assessment dated [DATE] indicated resident #403's caloric needs were estimated at 2189-2975 calories/day. On 2/11/25 at 9:30 AM, resident #403 stated he only got a sausage, a small donut, and a glass of juice and milk for breakfast, and he was still hungry. He stated he had been at the facility about a week and a half and he was not aware he could make food selections from the menu. Resident #403 added no one from the staff had discussed his food preferences with him. Occupational Therapist (OT) M brought the resident a 2nd meal tray because he told her he wanted more food. OT M stated the tray she brought was a leftover, untouched tray for another resident who had gone to the hospital. Resident #403 acknowledged the food provided was cold, but stated he didn't care because he was hungry. On 2/12/25 at 11:16 AM, the DTR confirmed resident #403's caloric needs were estimated at 2189-2975 calories/day and acknowledged his nutritional needs could be very difficult to meet when the menu provided approximately 2000-2200 calories per day. She added snacks were available from the nursing stations. The DTR stated the resident seemed fine with the food and confirmed she didn't discuss food preferences with this resident. The DTR acknowledged the facility did not offer resident #403 large portions or discuss options for the resident to fill out menus to better meet his hunger and nutritional needs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105671 If continuation sheet Page 18 of 23 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 02/14/2025 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 On 2/14/25 at 9:30 AM, the Regional Nurse stated they expected staff to check the resident's diet order and go to kitchen to get a resident fresh, warm food according to their diet order, if they asked for more food. The DON and the DTR were in agreement, and the DTR added that serving a leftover tray to another resident was not acceptable. The DON stated she would have stopped the staff and told them to get fresh food from the kitchen because any food that was out, could have been touched by someone else. Residents Affected - Many 3. Resident #34 was admitted to the facility on [DATE] with diagnoses that included End Stage Renal Disease (ESRD) with dependence on renal dialysis, chronic pain syndrome, secondary malignant neoplasm of the breast, gout, depression, anxiety, dementia without behavioral disturbance, and primary insomnia. The physician orders for for February 2025 indicated resident #34 was on a Renal diet. Review of the Nutrition Comprehensive Evaluation dated 1/16/25 revealed resident #34's food intake varied between 25-100% of meals and was inadequate to meet her needs which were estimated to be between 2400-2800 calories and 96-112 grams protein /day. On 2/11/25 at 9:23 AM, resident #34, acknowledged she had been at the facility about 4 weeks, and stated she didn't like the food. She explained she had asked her aide to be able to select her meals herself but was never given a menu to do so. On 2/12/25 at 11:16 AM, the DTR reviewed the nutrition assessment for resident #34 dated 1/16/25. She acknowledged the assessment indicated the resident was not meeting her nutritional needs, her appetite was diminished, and she was not interested in the food served at the facility, but agreed to receive the nutrition supplement, Nepro. The DTR verified there was no indication food preferences were discussed or an attempt to try to provide foods the resident liked to eat. The DTR confirmed the Nepro supplement had not been ordered for the resident which she said was her error. The DTR added she believed someone on the nursing staff explained the option to fill out menus to the residents, but she was not sure who did it. On 2/12/25 at 9:55 AM, the Dietary Services Manager stated when residents got admitted to the facility, he visited them to get their food preferences and let them know they could get menus from the nursing station or their Certified Nursing Assistant (CNA) to select their meals. He added that the DTR or the Registered Dietitian (RD) also then met with residents when they assessed their nutritional status and would communicate any additional preferences to him through email. The Dietary Services Manager checked his computer for residents #77, #403, and #34 and found no preferences, no dislikes, and no documentation that the residents were spoken with about their food requests. On 2/11/25 at 9:08 AM, CNA D stated the 3 PM-11 PM shift CNA's gave menus to residents when they asked for one and put extra menus by the nursing station. She added new CNA's were trained to tell new residents there were menus available when they got admitted . On 2/12/25 at 5:11 PM, CNA C stated when a resident was first admitted , the CNA's explained there were menus for selecting lunch and dinner meals, but menus were not passed to residents who were on pureed, mechanical soft, or renal diets. She pointed out a couple of specific residents who received menus to fill out for the next day. She acknowledged that sometimes residents may be overwhelmed when they were first admitted , and she acknowledged it might be helpful if the information was repeated to them. 4. Resident #59 was admitted on [DATE] with diagnoses of acute respiratory failure with hypoxia, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105671 If continuation sheet Page 19 of 23 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 02/14/2025 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 - Many pneumonia, unspecified intracranial injury, type II diabetes mellitus, protein-calorie malnutrition, chronic pain, muscle weakness, and major depressive disorder. Review of physician orders for February 2025 indicated she was ordered a regular diet. Resident #59's Comprehensive Nutrition assessment dated [DATE] indicated she had a low Body Mass Index (BMI) of 21.3, had significant weight loss in the recent past and ate her meals independently with set-up. The assessment revealed the resident stated she was sometimes hungry between meals and desired beneficial weight gain. The document described the resident agreed to some large portions and her preferences were discussed. On 2/10/25 at 5:49 PM, CNA A delivered resident #59's dinner tray into her room, set it down and indicated to the resident the meal was there, and left the room. The resident opened the lid from her food plate and realized what she received was not what she had ordered, which was corroborated by her menu. A few minutes later CNA A stated staff were supposed to check the resident's menu ticket to ensure they actually received what was on the ticket when they delivered the meals. She added she just dropped the tray off to this resident because she knew the resident could set up her own tray and she figured the resident would ask if something was missing. She then acknowledged she left the resident's room so quickly, the resident hadn't had a chance to look at her meal or request what food items she hadn't received on her ticket. On 2/12/25 at 10:28 AM, the Director Of Nursing (DON) stated when CNA's delivered meal trays to residents, she expected them to sanitize their hands prior to getting their meal, to ensure the meal tickets matched the resident's name and food items on their tray, and the tray included the utensils and drinks listed on the ticket. The facility's policy entitled, Food and Nutritional Services dated 3/02/19, indicated the facility would provide a nourishing, palatable, well-balanced diet that met the daily nutritional and special dietary needs of the residents, taking into consideration their preferences. The document continued that the facility employed sufficient staff with appropriate competencies and skill sets to carry out the function of food and nutrition service. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105671 If continuation sheet Page 20 of 23 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 02/14/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, and interview, the facility failed to serve food items in accordance with professional standards for food service safety. Specifically, potentially hazardous food items were held and served while in the temperature danger zone having the potential to affect 95 of the 98 residents at the facility. Findings: On 2/12/25 at 4:40 PM, the dinner tray line was in process when tuna salad sandwiches were noted to be stacked in a full, deep sheet pan sitting in one of the wells of the steam table being used to plate hot entrees. The heating element for the steamtable well which held the sandwiches along with the well directly adjacent to it, were turned off but were warm to the touch as heat radiated from the other heated wells further down on the table. The Dietary Services Regional Manager took the temperatures of the sandwiches which recorded at 50 degrees Fahrenheit (F). The evening (PM) cook removed the tuna sandwiches from the tray line and put them in the freezer to re-chill. The Regional Manager removed a 2nd deep full-size steamtable pan of tuna salad sandwiches from the freezer and measured the temperature of random sandwiches, which was found to be 46.7 degrees F, in the danger zone for potentially hazardous foods. The Regional Manager put the 2nd steamtable pan of sandwiches back into the freezer and told the cook and kitchen staff that the tray line should stop and was not able to continue until the sandwiches were cooled to a safe serving temperature of at least 41 degrees F. The PM cook stated the pan of sandwiches were usually on a bed of ice in the steamtable wells, but the ice machine was not producing ice at that time, so no ice was available for the tray line. A few minutes later, the Dietary Service Manager provided the temperature log that contained the pre-tray line temperatures of foods from the tray line. The cook stated she had taken the temperatures approximately 20 minutes earlier, at the start of tray line, and the sandwich temperature was recorded at that time as 38 degrees F. The Dietary Services Manager stated he did not have an explanation for how sandwiches whose temperature was recorded at 38 degrees F twenty minutes prior then placed in the freezer had actually warmed to 46.7 degrees F. He stated at approximately 2:30 PM, he talked with the PM cook while she prepared the sandwiches and he witnessed her put the sandwiches in the freezer around that time. On 2/13/25 at 12:10 PM, the Dietary Services Regional Manager stated it was common at facilities to put cold sandwiches into the freezer to chill them quickly then move them into a refrigerator when they were at a safe temperature. He acknowledged the sandwiches that tested 46.7 degrees F in the freezer, must not have been placed there long enough to be chilled, and were not at a safe temperature to be served. The facility's Food and Nutrition Services policy dated 3/02/19 detailed the facility would store, prepare, distribute, and serve food in accordance with professional standards for food service safety. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105671 If continuation sheet Page 21 of 23 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 02/14/2025 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 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Level of Harm - Minimal harm or potential for actual harm Based on interview, and record review, the facility failed to ensure that the binding arbitration agreement explicitly granted the resident or their representative the right to rescind the agreement within 30 calendar days of signing it for 18 of 102 current residents who signed arbitration agreements. Residents Affected - Many Findings: Review of the log provided by the facility revealed 18 of the current 102 residents signed the facility's arbitration agreement. On 2/13/25 at 1:59 PM, the Internal Admissions staff person verified she completed most of the admission packets with residents or their representatives within 48 hours of admission. She stated she usually read the Voluntary Binging Arbitration Agreement to the resident or their representative. She confirmed the agreement was not a requirement for admission. She explained the resident or their representative could change their mind after signing but was not sure of the time frame. The Internal Admissions staff person reviewed the arbitration agreement and confirmed it gave the resident or their representative 30 calendars of the resident's date of admission to rescind the agreement, not from the date of signature. Review of the facility's Voluntary Binding Arbitration Agreement revealed the document was voluntary and was not a requirement for admission. The document defined the parameters of an arbitration and indicated the document could be rescinded within 30 days of the resident's date of admission to the facility. On 2/13/25 at 2:03 PM, the Regional [NAME] President of Operations reviewed the right to change your mind clause in the Voluntary Binding Arbitration Agreement. She acknowledged the wording did not explicitly grant the resident/resident representative 30 days from the date of signing to rescind the agreement. The Regional [NAME] President of Operations agreed the resident/resident representative would not have 30 days from date of signature to rescind the agreement if it differed from the date of admission, but stated she did not think any residents had been affected since no one had requested to rescind the agreement. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105671 If continuation sheet Page 22 of 23 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 02/14/2025 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 0865 Have a plan that describes the process for conducting QAPI and QAA activities. Level of Harm - Minimal harm or potential for actual harm Based on interview, and record review, the facility failed to maintain records, monitor, and effectively conduct Quality Assurance Performance Improvement (QAPI)/Quality Assurance and Assessment (QAA) activities which could affect facility wide processes impacting quality of care and quality of life for all residents. Residents Affected - Many Findings: On 2/14/25 at 8:43 AM, in a joint interview with the Director of Nursing (DON) and Regional Director of Clinical Services, the Director said she initiated a Performance Improvement Plan (PIP) approximately one month prior for Pre-admission Screening and Resident Review (PASARR). She stated in regards to resident PASARRs, I would say maybe 25% have been looked at and some were redone. She said she had to locate the documentation and audits to clarify. On 2/14/25 at 10:08 AM, the Regional Director of Clinical Services explained she was unable to locate any records for the PIPs and stated, they're not on record and not organized. On 2/14/25 at 11:59 AM, the Nursing Home Administrator (NHA) said she had been the NHA since 1/14/25. She explained she had conducted QAPI meetings on 1/14/25 and 1/16/25. She explained the last meeting included discussions concerning regulatory compliance and survey management. She said she initiated a PIP for facility wide environmental concerns and maintenance repairs. The NHA checked previous records that showed a QAPI meeting was conducted in December 2024 with notes that PIPs were implemented for facility issues with infection control, respiratory/tracheostomy care, and PASARR. A handwritten log was observed in the binder that noted the titles of PIPs she verbalized. No reports or documents related to the PIPs aside from the environmental/maintenance plans were located in the NHA's QAPI records. The NHA was unable to locate any records for clinical PIPs and said she could not speak to what occurred before she took over. The NHA stated, there are no records for clinical; QAPI is in place to monitor, analyze, and correct problems so residents get the care and services they need and have the right to. Review of the Quality Assurance Meeting minutes dated 1/14/25 provided by the NHA noted there were no QAA Committee recommendations, and read, Plan implemented based on recommendations: N/A Review of the facility's standards and guidelines titled Quality Assurance and Performance Improvement and dated 3/2/19 read, The facility will: 1. Maintain documentation and demonstrate evidence of it's ongoing QAPI program that meets the requirements of this section. This may include but is not limited to systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events, and documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities . 3. Present documentation and evidence of it's ongoing QAPI program's implementation and the facility's compliance with the requirements to a State Survey Agency, Federal Surveyor, or CMS (Centers for Medicare & Medicaid Services) upon request. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105671 If continuation sheet Page 23 of 23