Health inspection·February 7, 2020

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete confirmed if the resident had a low blood pressure documented a follow up note and physician notification should be found along with a resident assessment. Review of the policy and procedures for physician notification 4.2.1 page one of one dated November 2017 reflected: The facility strives to ensure that each resident's health is supervised by a qualified attending physician. The attending physician in the facility is ultimately responsible for supervision and management of the care of the representative/patient. 1) Licensed nurses will ensure that physicians are notified of changes or diagnostic results that occur between visits. Changes may include but are not limited to: A change in condition, mental or physical. laboratory results. Diagnostic results. Resident's refusal to take medication. Event ID: Facility ID: 105176 If continuation sheet Page 2 of 12 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 105176 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winter Haven Health and Rehabilitation Center 202 Ave O NE Winter Haven, FL 33880 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Observation of Resident #102 on 2/4/20 at 9:40 a.m. reflected the resident lying in bed with the bed in low position. The [indwelling] catheter was observed on the floor with dark yellow urine. Observation of Resident #102 on 2/5/20 at 9:30 a.m. reflected the resident lying in bed without a catheter observed from the sides of the bed. The resident was lying flat on his left side. The resident stated the catheter was on his left leg and lifted his shorts to expose the bottom of the catheter on the left inner thigh. Resident #102 gave permission to look in his restroom. Observed on the grab bar behind the toilet on the left side, was a clear plastic bag tied tight on the grab bar with a used urinary catheter bag inside. At that time a housekeeper walked in the bathroom and pulled on the clear plastic bag and stated why would someone tie this up here. (Photographic evidence was obtained.) During an interview with Staff K, CNA on 2/5/20 at 9:33 a.m.she stated Resident #102 is ambulatory and uses a bed bag at night and gets up to go to the bathroom and walks in the hallway at night, so he will wear a leg bag during the day and bed bag at night. The nurse will connect the bag from leg bag to bed bag and store it in the bathroom in a plastic bag. The bag is emptied and stored in the bag without cleaning out the bag or rinsing it. During an interview on 2/06/20 at 5:45 p.m. with Staff H, Regional Nurse Consultant (RNC) she confirmed the catheter bags are for one use only and should not be stored and reused. Review of the physician order reflected to provide catheter care every shift dated 12/7/19. Review of the care plan focus area initiated on 11/14/19 reflected the resident uses a urinary catheter with risk for infection and or complications. Goal to minimize the risk of complications associated with catheter usage initiated 11/14/19. Interventions included provide catheter care daily and as needed initiated on 11/14/19. Change drainage bag as needed. Leg bag while out of bed initiated on 2/5/20. Keep drainage bag below level of bladder initiated 11/14/19. During an interview on 2/07/20 at 3:09 p.m. The Director of Nursing (DON) stated she started educating staff that catheters are single use only. Review of the disposable urinary drainage with privacy cover reflected a 2 with a circle around it with the words DO NOT REUSE. Review of the Guideline for Prevention of Catheter-Associated Urinary Tract Infections (2009) revealed: III. Proper techniques for urinary catheter maintenance. A. Following aseptic insertion of the urinary catheter, maintain a closed drainage system. 1. If breaks in aseptic technique, disconnection, or leakage occur, replace the catheter and collecting system using aseptic technique and sterile equipment. Based on observations, interviews, and record reviews, the facility did not ensure appropriate treatment and services were provided to prevent urinary tract infections (UTI) for two residents (#76 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105176 If continuation sheet Page 3 of 12 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 105176 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winter Haven Health and Rehabilitation Center 202 Ave O NE Winter Haven, FL 33880 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 0690 and #102) of three residents sampled for UTIs. Level of Harm - Minimal harm or potential for actual harm Findings included: Residents Affected - Few Resident #76 was admitted to the facility on [DATE] with diagnoses of sepsis, chronic kidney disease, urinary tract infection, and obstructive and reflux uropathy. A review of Resident #76's care plan revealed that Resident #76 used a urinary catheter with risk of infection and/or complications related to obstructive uropathy with an intervention to keep the catheter tubing free of kinks. A review of Resident #76's physician's orders revealed an order to observe Resident #76's [indwelling] catheter each shift. Resident #76's physician's orders also revealed an order to drain Resident #76's catheter bag every shift and as needed. An interview was conducted on 02/05/20 at 10:34 a.m. with Resident #76 regarding care at the facility. Resident #76 stated that he had experienced frequent UTIs associated with his [indwelling] catheter and that his [indwelling] catheter had not been emptied by certain staff members at the facility as it should be every shift. An observation of Resident #76's [indwelling] catheter bag at the time of the interview confirmed a small amount of clear yellow urine in Resident #76's [indwelling] catheter bag. During the observation, a small bend was observed in Resident #76's [indwelling] catheter tubing at the point that the catheter tubing attached to the catheter drainage bag. No urine was observed in the [indwelling] catheter tubing at the time of the observation. An observation was made on 02/06/20 at 10:27 a.m. of Resident #76's [indwelling] catheter drainage bag and tubing. Resident #76's catheter tubing was observed to be kinked at the point that the catheter tubing attached to the catheter drainage bag, causing urine to collect approximately half way up the urinary catheter tubing (photographic evidence obtained). Resident #76 then pushed his call light and Staff E, Certified Nursing Assistant (CNA) responded. Staff E observed Resident #76's catheter tubing and noticed that the tubing was kinked with urine backed up into the tubing. Staff E then repositioned the catheter tubing and ensured that urine was following into Resident #76's catheter drainage bag. Staff E stated that she would let the nurse know that the catheter tubing was kinked and not draining urine properly. A follow up observation was made on 02/06/20 at 6:11 p.m. of Resident #76's catheter tubing and drainage bag. Resident #76's catheter tubing was observed to be kinked at the point that the catheter tubing attached to the catheter drainage bag, causing urine to collect approximately half way up the urinary catheter tubing. A small amount of clear yellow urine was observed in Resident #76's catheter drainage bag. An observation was made on 02/07/20 at 7:55 a.m. of Resident #76's catheter tubing and catheter drainage bag. Resident #76's catheter tubing was observed to be kinked, causing urine to be backed up about one quarter of the way up the catheter tubing. Resident #76's catheter drainage bag had a small amount of clear yellow urine inside. An observation and interview was made on 02/07/20 at 9:58 a.m. with Staff C, CNA and Staff D, Registered Nurse (RN) of Resident #76's catheter tubing and care. Staff C stated that she emptied Resident #76's about every 2 hours and anytime that she provided care to the resident. Staff C and Staff D observed Resident #76's catheter tubing and noticed a kink at the point that the catheter tubing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105176 If continuation sheet Page 4 of 12 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 105176 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winter Haven Health and Rehabilitation Center 202 Ave O NE Winter Haven, FL 33880 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few attached to the catheter drainage bag, causing urine to collect approximately one third up the urinary catheter tubing. Staff D stated that if catheter tubing is kinked and urine flow is obstructed then they would reposition the tubing to allow urine to flow in the drainage bag or change the catheter tubing and drainage bag. Staff D also stated that Resident #76's catheter tubing needed to be changed due to the tubing being kinked. Staff C stated that if they discovered a resident had catheter tubing that was kinked or obstructed, then she would inform the nurse so it could be assessed. A follow up interview was conducted on 02/07/20 at 10:22 a.m. with Staff D regarding Resident #76's catheter tubing. Staff D stated that she changed Resident #76's catheter tubing and drainage bag due to the kink in the tubing. Staff D stated that Staff E did not inform her on 02/06/20 that Resident #76's catheter tubing was kinked and also stated that Staff E may have gotten busy and forgot to inform her. Staff D stated that the CNAs had been emptying Resident #76's catheter drainage bag due to increase fluids and that build up of urine in the catheter tubing could contribute to UTIs if not corrected timely. An interview was conducted on 02/07/20 at 4:48 p.m. with the facility's Director of Nursing (DON) regarding care of urinary catheters and expectations of staff. The DON stated that CNAs are able to empty the catheter drainage bags as well as provide catheter care and that nurses address concerns such as blockages, leakage, or occlusions in the resident's catheter tubing. The DON also stated that if a kink in a resident's catheter tubing is found by a CNA, then it should be reported to the nurse. The DON stated that if drainage of urine is occluded by blockage or kinked tubing then it can cause risk for infection or discomfort for the resident. The DON also stated that if catheter tubing is kinked then the nurse would assess or evaluate the tubing to determine the next step and determine if the catheter tubing and bag need to be replaced. The DON stated that staff should be observing the resident's catheter tubing and bag whenever they are in the room performing care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105176 If continuation sheet Page 5 of 12 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 105176 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winter Haven Health and Rehabilitation Center 202 Ave O NE Winter Haven, FL 33880 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews the facility failed to ensure ongoing communication between the facility and the dialysis care center for one resident (#184) of one sampled resident of a total of three residents who received dialysis care and services. Residents Affected - Few Findings included: Resident #184 was admitted to the facility on [DATE] with a diagnosis of hypertensive chronic kidney disease with stage 5 end stage renal disease. A review of the medical record revealed physician orders for: Dialysis arterial-venous (AV) shunt monitor every shift for bruit and thrill shunt is located at left arm; Epogen to be given at dialysis center during dialysis and Resident to have dialysis on days Tuesday/Thursday/Saturday at dialysis center. A review of the comprehensive care plan for Resident #184 initiated on 1/22/20 revealed the following focus area: Focus: Resident #184 has renal failure and is on hemodialysis. At risk for infection at venous access: Arteriovenous Fistula (AVF) Goal: Will have no untreated injury/bleeding at access site. Will have minimal to no complications related to nutritional intake. Interventions: Dialysis days Tuesday, Thursday, Saturday, Dialysis time 3 p.m., Catheter site Left arm, Diet as ordered, Encourage resident to go for the scheduled dialysis appointments, Encourage rest as needed and participation in preferred activities, Registered Dietician consult as needed and Notify physician for any changes as needed. On 2/6/20 at 9:05 a.m. Resident #184 was observed sitting on the bed in her room. She appeared clean, dry and was fully dressed. A clean dressing was observed on the left foot. Resident #184 was available for interview and stated she came to the facility after a hospitalization due to a deep vein thrombosis that formed in her left leg. Resident #184 stated she was preparing to go to dialysis for a treatment. The resident stated she receives treatments three times a week at the dialysis center and then returns to the facility. The resident stated she was waiting for transportation to her appointment. On 2/6/20 at 9:10 a.m. an interview was conducted with Staff B, Licensed Practical Nurse (LPN). Staff B, LPN stated she had just finished giving Resident #184 her medications and was preparing the resident for transport to the dialysis center. Staff B, LPN stated she was responsible for completing the dialysis communication sheet with vital signs and all pertinent information needed by the dialysis center at the top of the form before the resident departs. Staff B, LPN stated the communication sheet goes with the resident in a binder to the treatment. Staff B, LPN stated the dialysis center is responsible for filling in the middle section of the form with information related to the treatment and then return the form to the facility with the resident. Staff B, LPN stated upon return, the nurse fills in the bottom section of the form with the assessment of the resident. A review of the Dialysis Communication Tool located in the binder for Resident #184 revealed on 2/4/20, 1/30/20 and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105176 If continuation sheet Page 6 of 12 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 105176 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winter Haven Health and Rehabilitation Center 202 Ave O NE Winter Haven, FL 33880 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 1/28/20 no documentation was present in the information from dialysis center sections of the forms; no documentation was present in the return section for the facility nurse on the forms. Staff B, LPN confirmed there was not documentation on the forms indicating what occurred during dialysis treatments and there was not documentation from the nurse indicating the assessment when the resident returned to the facility. A review of the facility policy titled, Dialysis Management (Hemodialysis), dated October 2017 revealed the following: Overview: The facility will coordinate care and services for hemodialysis residents. Facility will coordinate routine transportation for the resident. Contractual agreement will include, but may not be limited to the following: Medical and non-medical emergencies Development and implementation of resident care plan Interchange of information useful/necessary for the care of the resident Guidelines: 8 Complete the dialysis communication tool before and after dialysis and following up on any special instructions from the dialysis center 10 Evaluate for and manage post dialysis complication which may include, but are not limited to the following: confusion, fever, pruritus, anaphylaxis, seizures, hypotension, muscle cramps, cardiac arrhythmia, restlessness, air embolus, insomnia, hemorrhage. On 2/6/20 at 5:41 p.m. an interview was conducted with the Administrator, the Director of Nursing (DON) and the Regional Risk Manager. The DON stated the nurses are expected to fill out the dialysis communication forms before and after each dialysis treatment. The Administrator, DON and Regional Risk Manager confirmed the communication sheets for Resident #184 were not completed as required on 2/4, 1/30 or 1/28. The DON stated the dialysis center has not been filling in the middle portion of the form so the medical records department has been requesting a report from the dialysis center, but they do not get that information to the nurse right after the treatment. The DON was unable to locate a nursing assessment in the medical record for Resident #184 after each dialysis treatment on 2/4, 1/30 or 1/28 that was completed by the nurse. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105176 If continuation sheet Page 7 of 12 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 105176 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winter Haven Health and Rehabilitation Center 202 Ave O NE Winter Haven, FL 33880 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews the facility failed to ensure that medications were delivered as prescribed for one resident (#120) of eight sampled residents. This resulted in medications being administered crushed in a manner that was not recommended by the manufacturer for Resident #120. These 2 errors observed during the medication administration of 25 total medications represented an error rate of 8.0%. Residents Affected - Few Findings included: Resident #120 was admitted to the facility on [DATE] with diagnoses of cerebral infarction, essential hypertension, type 2 diabetes mellitus, dementia, hypokalemia, peripheral vascular disease and hyperlipidemia. A review of the medical record revealed current medication orders as of February 2020 for Amlodipine Besylate tablet 5 Milligram (mg) tablet one time a day, Aspirin 81 mg tablet one time a day, Baclofen 5 mg tablet two times a day, Chlorthalidone 25 mg tablet one time a day, Gabapentin 400 mg capsule three times a day, Metformin Hydrochloride 500 mg tablet two times a day, Metoprolol Tartrate 25 mg tablet two times a day, Multivitamin with minerals tablet one time a day and Potassium 20 Millequivalants (meq) one time a day. On 2/06/20 at 9:35 a.m. a medication administration observation was conducted with Staff A, Licensed Practical Nurse (LPN) for Resident #120. Staff A, LPN verified the resident to be Resident #120. Staff A, LPN pulled the following medications from the medication cart for administration: 1 Amlodipine Besylate 5 mg tablet, 1 Aspirin 81 mg tablet enteric coated, 1 Baclofen 10 mg ½ tablet, 1 Chlorthalidone 25 mg tablet, 1 Gabapentin 400 mg capsule, 1 Metformin Hydrochloride 500 mg tablet, 1 Metoprolol Tartrate 25 mg tablet, 1 Multivitamin with minerals tablet and 1 Potassium Chloride 20 meq Extended Release (ER). Staff A, LPN proceeded to crush all of the tablets and open the capsule and place the contents into a medicine cup. Staff A, LPN mixed all of the pill contents with applesauce for administration to Resident #120. Staff A, LPN entered the resident room with the medication cup and proceeded to administer the medications to Resident #120 with a spoon. Staff A, LPN returned to the medication cart after administration of the medications. An interview with Staff A, LPN was conducted at the medication cart directly after exiting the room. Staff A, LPN was asked how she is able to identify when medications can be crushed. Staff A, LPN stated she can identify if medications can be crushed by reviewing the orders in the computer for each resident and by looking at the medication packaging. Staff A, LPN identified an order for Resident #120 that allows for medications to be given in any form needed. On 2/7/20 at 3:54 p.m. an interview was conducted with the Consulting Pharmacist. The Pharmacist confirmed that enteric coated aspirin and extended release Potassium tablets should not be crushed. The Pharmacist stated the medications both appear on the Pharmacy Name Do Not Crush List available in the facility. A review of the facility policy, Medication Administration General Guidelines Section 7.1, with a date of 12/12 indicated the following: Policy: Medications are administered as prescribed in accordance with manufacturers' (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105176 If continuation sheet Page 8 of 12 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 105176 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winter Haven Health and Rehabilitation Center 202 Ave O NE Winter Haven, FL 33880 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 0759 Level of Harm - Minimal harm or potential for actual harm specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer mediations do so only after they have familiarized themselves with the medication. Procedures: Residents Affected - Few 1-Medications are prepared only by licensed nursing, medical, pharmacy or other personnel authorized by state regulations to prepare medications. 3-Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record (MAR). Compare the medication and dosage schedule on the resident's MAR with the medication label. 5-If it is safe to do so, medication tablets may be crushed or capsules emptied out when a resident has difficulty swallowing or is tube-fed, using the following guidelines and with a specific order from prescriber. a-The need for crushing medications is indicated on the resident's orders and the MAR so that all personnel administering medications are aware of this need and the consultant pharmacist can advise on safety and alternatives, if appropriate, during medication regimen reviews. b-Long-acting, extended release or enteric-coated dosage forms should generally not be crushed; an alternative should be sought. f-Crush medications if indicated for this resident only after referring to the Medications Not To Crushed List. For products that appear on the Medications Not To Be Crushed List, check with pharmacist regarding a suitable alternative, and request a new prescriber order if appropriate. A review of the Pharmacy Name Medications Not To Be Crushed document (revised 01/12) provided by the facility for review indicated Aspirin enteric coated tablets and Potassium Chloride tablets were not to be crushed for administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105176 If continuation sheet Page 9 of 12 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 105176 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winter Haven Health and Rehabilitation Center 202 Ave O NE Winter Haven, FL 33880 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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure one (#4) of 4 sampled residents, received laboratory services as ordered. Residents Affected - Few Findings included: During a phone interview on 2/07/20 at 11:05 a.m. with Resident #4's daughter, she stated her father had been at the facility for a while and that she is in communication with the facility. The daughter stated her father was currently hospitalized with a low blood pressure, slight fever and elevated white blood count (WBC) and has a bad history of Methicillin resistant staphylococcus aureus (MRSA). The daughter confirmed he was improving after an IV with antibiotics. Review of hospital emergency department rapid triage documentation dated 2/6/20 at 10:02 a.m. revealed, resident presented blood pressure of 90/39, temperature 99.1, pulse 82. Emergency department pre arrival summary - Needs sternal rub, altered mental status. Dilaudid 6 p.m. and 6 a.m. and Percocet at midnight and 6 a.m. Review of the ARNP progress notes dated 1/20/20 reflected Resident #4 recently sent to the hospital for sepsis evaluation. Review of physician telephone orders dated 1/20/20 signed by the ARNP reflected an order for CBC, BMP am. Review of lab monitor sheet dated 1/22/20 reflected tests ordered CBC/BMP, comments stated not able to draw. Review of lab monitor sheet dated 1/23/20 reflected tests ordered CBC, BMP, comments stated unable to obtain. Review of lab monitor sheet dated 1/24/20 reflected tests ordered CBC, BMP initialed without comments. Review of the lab results dated 1/23/20 reflected blood UTO (unable to obtain. Review of lab results dated 1/24/20 reflected CBC results still pending. BMP completed with special note reflecting : specimen hemolyzed. The specimen received was unsatisfactory for potassium analysis. Please resubmit. Review of lab results dated 1/25/20 reflected patient refused, ARNP signed with re-attempt written. Review of ARNP progress notes dated 12/12/19 reflected resident recently sent to hospital for evaluation of fever, found to be anemic, given transfusion. Review of physician telephone orders dated 12/12/19 reflected CBC, BMP am. Review of lab results dated 12/9/19 reflected vancomycin pre-dose (trough) completed. Review of labs dated 12/13/19 reflected patient refused signed by ARNP with reattempt written. Review of lab results dated 12/16/19 reflected vancomycin pre-dose (trough) completed. Review of lab results dated 12/20/19 reflected tests not performed. During an interview 2/06/20 at 10:10 a.m. with the physician's ARNP, she stated the resident recently came back from the hospital and that is the last time she saw him. The ARNP stated Resident #4 has anemia, he is very sick man, extremely contracted. The ARNP stated sometimes we have to reattempt his labs due to him not wanting them at that time. The ARNP stated that ordered labs should be completed. The ARNP stated that she orders the labs then the lab results go in her book to sign and reorder labs as needed. The ARNP stated she goes through the book weekly and was not aware the labs (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105176 If continuation sheet Page 10 of 12 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 105176 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winter Haven Health and Rehabilitation Center 202 Ave O NE Winter Haven, FL 33880 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 0770 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few ordered were incomplete for Resident #4. The ARNP stated if the resident chose not to have labs that day the staff should reattempt until completed. The ARNP restated she is in the building from one to three times a week and the physician is in at least once a week. During an interview on 2/06/20 at 1:26 p.m. with staff member F, LPN, she stated they notify the family for new orders and put the orders in the computer. When they receive the results they notify the doctor. Staff member F, LPN stated she notifies the doctor if the resident refuses then will try again the next day. Staff member F, LPN stated she would look at the lab book or the orders if she was out to see what labs were ordered and received. During an interview on 2/06/20 at 1:31 p.m. The DON stated the lab book and tracker are filled out for each resident with requisition form. The lab tech comes in and the tech should document in the lab book if the lab was completed or not. The lab tech should discuss with the nurse any issues they encountered. The DON stated the lab book comes to the morning meeting and they discuss it every day and look to see if the nurses are completing the book by recording the labs were received and the physician and family notified and any new orders documented. The DON stated they have had management change and she has told the nurses to make the lab books their best friends by looking at the book several times and making sure they have contacted the family and the physician. The DON was asked where Resident #4's CBC (complete blood count) and BMP (basic metabolic panel) results were from 12/12/19 and CBC results from 1/20/20 and she stated she was concerned as she could not find the completed labs except from the ones taken at the hospital. The DON stated that the nurses would draw labs if the resident had a central line in the facility. The DON confirmed Resident #4 had IV's that were maintained but was unsure if they were midlines or central lines and stated the lab could not draw off those only the nurses. The DON could not answer why the resident's vanco orders were followed and the CBC and BMP were not. The DON stated that she would expect the nurse to followup and reattempt the lab and confirmed the lab log was not completed for the 1/20/20 labs. During an interview on 2/06/20 at 3:56 p.m. with the Nursing home administrator (NHA), DON, Regional risk manager and Risk Manager (RM). The Risk manager stated she was notified of an investigation for Resident #4 while he was out to the hospital in January. The RM stated she reviewed the record and did not look at the resident's labs. She stated she reviewed the record related to wounds and stated if she was looking for albumin related to healing wounds she would have looked at the labs but did not. The RM stated she did see a lab that the resident refused but did not further investigate to see if the lab was completed. During an interview on 2/07/20 at 10:03 a.m. with the ADON, she was asked when the last CBC was located for Resident #4 and she stated she would look. The last CBC the facility completed for Resident #4 was obtained on 10/9/19. During an interview on 2/07/20 at 4:30 p.m. with Staff member I, Regional Nurse Consultant (RNC) she stated the facility is working on notification related to labs and x-rays but did not realize they were not capturing on the 24 hour reports the missing lab results if the lab was not drawn for a day or two. The RNC stated if a resident refuses or the lab can't be drawn and a new order is not written, the 24 hour report does not catch this problem and the labs are missed. The RNC stated the system is broken and the are continuing to work at capturing the labs. The RNC stated the physician's order should remain open until completed or canceled by the physician. Review of the policy and procedure, Laboratory services 12/1/1 page one of one, effective 1/1/20 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105176 If continuation sheet Page 11 of 12 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 105176 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winter Haven Health and Rehabilitation Center 202 Ave O NE Winter Haven, FL 33880 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 0770 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete reflected the facility will provide or obtain laboratory services to meet the needs of its residents/patients. The facility will be responsible for the quality and timeliness of services whether provided by the facility or an outside agency. The laboratory selected to perform the tests will be Medicare approved. 1) Assure laboratory tests or completed and results provided to the facility within timeframe's normal for appropriate intervention. 4) Assist the resident/patient in making transportation arrangements to and from the laboratory if specimen is unable to be obtained at the facility and if the resident patient needs assistance. 6) Monitor services, timeliness, and quality through the Quality assurance committee. Event ID: Facility ID: 105176 If continuation sheet Page 12 of 12