Health inspection·February 2, 2022

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some drops were expired and should have been discarded. The insulin vial, Humulin R, should not be used for multiple residents and should be labeled with residents name and order on the vial or it should not be in the medication cart drawer. She stated, I cannot find the expiration date on Resident #36's Fluticasone Propionate nasal spray label but the open date reads 7/16/21 and I know it was opened 6 months ago. She confirmed that Resident #77's Trulicity injection pen read an open date 7/2021. Trulicity Label read dispose of after 14 days and should not be left in the medication cart. The second Trulicity pen for Resident #77 was unopened and the label read refrigerate until opened and should not be in the medication cart but in the refrigerator until it was ready for use for the resident. During an interview on 1/30/2022 at 11:30 AM the Director of Nursing (DON) confirmed she had been informed of all medication storage concerns. She stated, I expect all expired medications to be disposed of or returned to the pharmacy. I expect medications to be stored in their original packages according to the manufacturer's directions and labeled with the dates opened or expired. Record review of the facility policy titled 5.3 Storage and Expiration of Medications, Biologicals, Syringes and Needles effective date 12/01/07, revised 10/31/16 reads Applicability: This policy 5.3 sets for the procedures relating to the storage and expiration dates of medications, biologicals, syringes and needles. Procedure: 4. Facility should ensure that medications and biologicals that; (1) have an expired date on the label: (2) have been retained longer than recommended by manufacturer or supplier guidelines: or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier. 5. Once any medication or biological package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. 11. Facility should ensure that medications and biologicals are stored at their appropriate temperatures according to the United States Pharmacopeia guidelines for temperature ranges. 2. On 1/30/2022 at 9:30 AM, an observation of the South Unit medication room revealed the refrigerator door was not locked. The lock was hanging open on the refrigerator door, the lock was not closed in a locked position and secured. During an interview on 1/30/2022 at 9:30 AM Staff A, LPN confirmed the lock was opened and not locked and the lock was hanging on the refrigerator. She stated that the refrigerator is supposed to be locked at all times. During an interview on 1/30/2022 at 9:30 AM Staff B, RN, Weekend Supervisor, stated that the refrigerator was to be locked at all times. All nurses are responsible to complete this task. During an interview on 1/30/2022 at 1:32 PM the DON stated that the medication refrigerator is to be locked at all times. On 1/30/22 at 9:45 AM an observation of the South Unit medication cart #1 revealed the following medications opened and not dated when opened: 1) Geni-Kot, 2) Iron tablets, 3) Senna Plus, and four (4) single individual plastic tubes of Ipratropium Bromide and Albuterol Sulfate Inhalation Solution not labeled for a specified resident. During an interview on 1/30/2022 at 9:45 AM, Staff A, LPN verified the medications were opened and not dated and stated that all medications are to be labeled with the open date when they are opened. Ipratropium Bromide and Albuterol Sulfate Inhalation Solution should be labeled with a resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106084 If continuation sheet Page 2 of 4 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 106084 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at Ocala, Inc 2021 SW 1st Ave Ocala, FL 34474 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 identifier. Level of Harm - Minimal harm or potential for actual harm On 1/30/2022 at 10:15 AM an observation of South Unit medication cart #2 revealed one bottle of opened insulin, Humulin 70/30, vial with an expired date of 1/19/2022 and labeled for Resident #92 and multiple medications opened with no open date placed on the bottle as follow: 1. Multivitamin, 2. Acidophilus with Pectin, 3. Loratadine 10 mg, 4. Melatonin 5 mg, 5. Omeprazole 20 mg, 6. Iron 325 mg, 7. Aspirin 81 mg, 8. Laxative Geni-Kot, and 9. Gamotidine 10 mg. Residents Affected - Some During an interview on 1/30/2022 at 10:15 AM, Staff D, LPN verified that Humulin Insulin 70/30 vial labeled for Resident #92 expired on 1/19/2022 and should have been wasted (discarded). She verified the following: 1. Multivitamin, 2. Acidophilus with Pectin, 3. Loratadine 10 mg, 4. Melatonin 5 mg, 5. Omeprazole 20 mg, 6. Iron 325 mg, 7. Aspirin 81 mg, 8. Laxative Geni-Kot, and 9. Gamotidine 10 mg. should have be dated when open and should be written on the bottle. During an interview on 1/30/2022 at 10:15 AM Staff B, RN, Weekend Supervisor, stated that all nurses are responsible for checking medication carts for expired medications and disposing of them. All medications are labeled with the open date when a nurse opens the vial. The Humulin 70/30 expired 1/19/2022 and should have been disposed of by expiration date. During an interview on 1/30/22 at 1:32 PM the DON stated that all medication carts are to be checked by the nurses daily and expired medication are to be thrown away. New medication when opened are to have the opened date written on the vial. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106084 If continuation sheet Page 3 of 4 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 106084 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avante at Ocala, Inc 2021 SW 1st Ave Ocala, FL 34474 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain medical records, accordance with accepted professional standards and practices, for each resident that are complete and accurately documented for 1 (Resident #4) of 3 residents sampled for catheter care. Findings: Resident #4 was re-admitted to the facility on [DATE]. Review of the Minimum Data Set Quarterly Assessment for Resident #4 dated 1/20/2022, Section H0100 reads Appliances. Indwelling catheter. Review of the physician orders for Resident #4 contained no orders for a Foley catheter, for catheter care, or for changing of the catheter bag. Review of the Medication Administration Record and Treatment Administration Record for Resident #4 follow re-admission revealed no documentation related to care of the indwelling catheter. Review of the Resident Centered Comprehensive Care Plan for Resident #4 read Focus: Resident has a urinary elimination condition/concern or is at risk for complications related to Obstructive Uropathy. Goal: The resident will maintain optimal status and quality of life without complications. Interventions included empty catheter bag every shift and PRN (pro re nata-as needed) and change catheter 18 French/20 Cubic Centimeter indwelling catheter per MD (Medical Doctor)/urologist order. Review of the Point of Care Response History for Resident #4 for catheter care from 1/15/22 - 2/1/22 revealed catheter care was not documented on 1/17/22, 1/18/22, 1/20/22, 1/24/22, and 1/27/22. During an interview on 2/01/2022 at 2:00 PM the Director of Nursing confirmed Resident #4 currently had an indwelling catheter and his medical record did not contain orders for the indwelling catheter, catheter care, or changing of the catheter bag since Resident #4 returned from the hospital on 1/14/2022. She stated catheter care was being provided by the staff and that Resident #4 was sent to the emergency room today due to blood colored drainage which continued after flushing of the catheter by the Registered Nurse on duty. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106084 If continuation sheet Page 4 of 4