Health inspection·October 22, 2021

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure an adequate supply of linens (towels) for eight (Residents #46, #102, #23, #70, #62, #2, #29, and #107) out of the sampled fifty-seven residents. Findings included: 1. On 10/21/21, starting at 10:00 a.m., a Resident Council Meeting was conducted in the Activities Room. Five (Residents #46, #102, #23, #70, and #62) of the ten residents that attended the meeting reported that they were always running out of towels. They reported that sometimes they were given pillowcases and sheets to dry off with after a shower or bed bath. The residents reported that the washing machines and dryers were always broken. The residents stated that the Certified Nursing Assistants (CNAs) were always going from room to room looking for towels. A record review of the admission Record for Resident #46 indicated that the resident was admitted into the facility on [DATE] with a primary diagnosis of hemiplegia and hemiparesis following cerebral infarction. Section C- Cognitive Patterns of the annual Minimum Data Set (MDS) dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating that he was cognitively intact. A record review of the admission Record for Resident #102 indicated that the resident was admitted into the facility on [DATE] with a primary diagnosis of muscle wasting and atrophy. Section C- Cognitive Patterns of the quarterly MDS dated [DATE] revealed that the resident had a BIMS score of 15 out of 15 indicating that she was cognitively intact. A record review of the admission Record for Resident #23 indicated that the resident was admitted into the facility on [DATE] with a primary diagnosis of muscle wasting and atrophy. Section C- Cognitive Patterns of the quarterly MDS dated [DATE] revealed that the resident had a BIMS score of 13 out of 15 indicating that he was cognitively intact. A record review of the admission Record for Resident #70 indicated that the resident was admitted into the facility on [DATE] with a primary diagnosis of chronic obstructive pulmonary disease. Section C- Cognitive Patterns of the quarterly MDS dated [DATE] revealed that the resident had a BIMS score of 14 out of 15 indicating that he was cognitively intact. A record review of the admission Record for Resident #62 indicated that the resident was admitted into the facility on [DATE] with a primary diagnosis of muscle wasting and atrophy. Section C- Cognitive Patterns of the admission MDS dated [DATE] revealed that the resident had a BIMS score of 11 out of 15 indicating that she was moderately impaired. On 10/21/21 at 1:50 p.m., Staff J, CNA, stated they were always running out of towels. She stated that this had been an issue for four or five months. She stated that when she could not find towels on the unit, she would go to laundry to look, or she would have to wait to do care. On 10/22/21 at 1:50 p.m., Staff I, Laundry Aide/Housekeeper, reported that one of the two washers was not working last month. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105176 If continuation sheet Page 2 of 14 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 10/22/2021 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 10/22/21 at 2:49 p.m., the Activities Director reported that the residents had voiced concerns about running out of towels maybe once or twice, but he did not recall the concern being mentioned in the Resident Council Meetings. He stated about a month and a half ago, the washer was broken but it was working now. On 10/22/21 at 5:09 p.m., the Administrator reported that they did not have a policy related to ordering supplies or inventory. 2. A tour of the building and resident wings was conducted on 10/19/2021 beginning at 9:30 a.m. At 10:10 a.m., Resident # 29 reported that there had been no towels for the aides to use when providing morning care or to provide to residents so they could perform their morning care. Resident #29 reported that it had happened before and usually meant that a laundry aide had called off and it took a long time to get someone to fill in for her. Resident #29 reported that the aide handed her a pillow case to dry her butt with that morning. Resident #29 had an quarterly Minimum Data Assessment conducted on 07/28/2021 which identified her as having a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive deficit. She was assessed as needing help with bathing as she was bed bound. At 10:40 a.m. on 10/19/2021, Resident # 2 confirmed that there were mornings when there were no towels available. When asked what had happened that morning, the resident responded that she had not yet received any towels - she was still waiting. The resident had an admission MDS conducted on 07/03/2021 which assessed her as having no cognitive deficit with a BIMS of 15. The resident was assessed as requiring one staff for extensive assistance with personal hygiene needs. At 11:45 a.m. on 10/19/2021, an aide (Staff H) was observed unlocking and entering the linen closet on the 100 unit. The rack of linen supplies contained two bath towels and a short stack of wash cloths that may have contained five or six cloths. While the aide was in the closet obtaining supplies for resident care, a resident was observed to self propel in her wheelchair up to the closet and ask the aide for towels. The aide gave the resident the two bath towels and a few washcloths. At 11:50 a.m., two CNAs were observed walking up to the linen closet on the 100 hall . They opened the closet and were asked what they were going to do about the availability of towels. Staff G reported that having no towels had happened before and they had heard that a laundry aide had called off. They reported that it must have taken time to replace her as it took time to get someone to start the laundry. The CNAs reported that they came in at 7:00 a.m. and they need supplies to get started. The CNAs reported that they usually check other units for supplies or ask other aides if they had some stashed that they can have. At 12:45 p.m. on 10/19/2021, Resident # 107 confirmed that on occasion there were no supplies. She confirmed that yes this morning they had no towels. She reported that the CNAs were saying that someone called off and she wasn't replaced until almost 9:00 a.m., which put everything back. Resident #107 was assessed on her quarterly MDS completed on 09/23/21 as having a BIMS of 15 indicating no cognitive deficit. Resident #107 was assessed as needing two staff to provide extensive assistance with her personal hygiene needs. On 10/20/21 at 9:40 a.m., Staff K CNA was observed leaving the linen closet on the 100 hall. The storage rack inside of the closet was observed to have no towels. When asked what she did in that situation, when there are no supplies, she reported that she would go to the laundry room as maybe the towels were ready and had not been brought out to the units. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105176 If continuation sheet Page 3 of 14 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 10/22/2021 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some At 10:20 a.m. the linen closet on the 100 hall was noted with 10 wash cloths and 5 bath towels. Resident # 29 confirmed at that time, she was just receiving her morning care. An interview was conducted with Staff F at 11:40 a.m. on 10/21/2021. She confirmed that she was the day shift laundry aide. She reported that she delivered clean linens to each unit several times a shift. She also reported that if the linen closets were empty, the aides know they could enter the clean laundry anytime and pick up their own supplies. Staff F confirmed she called off a few days earlier and heard that a housekeeper was pulled from her assignment to do the laundry that day. An interview was conducted with the Housekeeping Manager on 10/21/21 beginning at 11:50 a.m. He confirmed that his day laundry aide had called off on 10/19/21. By the time he was able to respond and get someone to do the laundry, it was several hours into the shift. He confirmed that there was a shortage of linens as many had to be tossed out as they were either torn or stained. He reported that he had a monthly inventory that he documented and when supplies were below the par level, the administrator would place the order. The housekeeping manager confirmed there were multiple deliveries to the units of linens and reported that he estimated each unit received 30 towels and 45-60 wash cloths during each delivery. The manager provided his October inventory, which he reported was due by the 15th of each month. The October inventory count indicated there were 563 wash cloths when the inventory was conducted the previous month. The total wash cloths needed, or the par level, was 250 . At the time of the inventory, there were 170 wash cloths in the building with 393 having been disposed of. The inventory of the bath towels showed the previous total was 202 with the par level of 189. At the time of the inventory, there were 231 bath towels in the facility with 43 towels having been disposed of. The inventory showed there were 78 wash cloths in resident rooms and 56 bath towels in resident rooms. The manager's supervisor joined the discussion and reported that wash cloths and bath towels were not supposed to be kept in the resident rooms. The supervisor and the manager both reported they were not aware that residents did not have towels the morning of 10/19/2021. When asked what the plan was for staff call offs, the manager reported that he had other staff that could fill in for the laundry aide. The supervisor agreed that there needed to be a plan for call offs so the replacement would be more timely. A review was conducted of the Facility's Assessment which included a section entitled Facility Resources needed to provide competent support and care for our resident population every day and during emergencies. Under the section for Physical Environment and building/plant needs, the guidelines included describe your processes to ensure adequate supplies and to ensure equipment is maintained to protect and promote the health and safety of residents. Under the Physical Resource Category of Non-medical supplies , bed and bath linens was included. The documented process was Contract with medical supply vendors to ensure items as needed. Continued in this section was the process for overseeing the services and how the services would meet the residents' needs. The assessment included the guidance, facility has contracts/agreements with transport, medical supply, food/water, hospice agencies and medical professionals to meet the needs. The assessment did not address the staffing component of providing linen services, only the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105176 If continuation sheet Page 4 of 14 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 10/22/2021 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 0584 physical aspect of the linens. Level of Harm - Minimal harm or potential for actual harm On 10/22/2021 beginning at approximately 4:30 p.m. an interview was conducted with the Administrator on the subject of lack of supplies and staff to provide those supplies. The Administrator reviewed the process he had with the housekeeping manager related to the inventory count and purchasing new linens. He confirmed every month they were purchasing supplies that included linens and towels. Related to the concern with replacing the staff who call off, he replied that there were other staff who could fill in when needed. He confirmed that there was no other plan except for trying to get others to fill in when needed. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105176 If continuation sheet Page 5 of 14 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 10/22/2021 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to resolve grievances related to cold food for five (Residents #46, #102, #23, #70, and #62) out of fifty-seven sampled residents. Findings included: A review of the Activities Resident Council Minutes dated 08/30/21 revealed that Resident #46 verbalized that the food was cold. The resolution revealed that the Dietary Manager explained that it might be related to the distance from the kitchen to the location of Resident #46's room. She verbalized that she would conduct a test run to make improvements with the food temperature. A review of the Activities Resident Council Minutes dated 09/09/21, revealed that the majority of the meeting was spent on dietary related issues such as chicken served too often and food over or under cooked. The solution indicated that the Dietary Manager explained to the residents that she would review the menu and check with corporate about changes to the menu. She also told the residents that she would let them know what type of changes to the menu were allowed. She informed the residents that she would monitor the food temperatures and timing of when the residents received their meals. A review of the Grievance/Concern Log for August and September 2021 did not reflect grievances voiced by the Resident Council related to cold food. On 10/21/21 starting at 10:00 a.m., a Resident Council Meeting was conducted in the Activities Room. Five (Resident #46, #102, #23, #70, and #62) of the ten residents that attended the meeting reported that the food was always cold. Resident #46 stated that he did not eat because the food was cold. Resident #62 stated that the eggs were rubbery, and the french toast was so hard that you could crumble it. The residents reported that when they report the concerns to staff, they just shrug it off and nothing was done. A record review of the admission Record for Resident #46 indicated that the resident was admitted into the facility on [DATE] with a primary diagnosis of hemiplegia and hemiparesis following cerebral infarction. Section C- Cognitive Patterns of the annual Minimum Data Set (MDS) dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating that he was cognitively intact. A record review of the admission Record for Resident #102 indicated that the resident was admitted into the facility on [DATE] with a primary diagnosis of muscle wasting and atrophy. Section C- Cognitive Patterns of the quarterly MDS dated [DATE] revealed that the resident had a BIMS score of 15 out of 15 indicating that she was cognitively intact. A record review of the admission Record for Resident #23 indicated that the resident was admitted into the facility on [DATE] with a primary diagnosis of muscle wasting and atrophy. Section C- Cognitive Patterns of the quarterly MDS dated [DATE] revealed that the resident had a BIMS score of 13 out of 15 indicating that he was cognitively intact. A record review of the admission Record for Resident #70 indicated that the resident was admitted into the facility on [DATE] with a primary diagnosis of chronic obstructive pulmonary disease. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105176 If continuation sheet Page 6 of 14 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 10/22/2021 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Section C- Cognitive Patterns of the quarterly MDS dated [DATE] revealed that the resident had a BIMS score of 14 out of 15 indicating that he was cognitively intact. A record review of the admission Record for Resident #62 indicated that the resident was admitted into the facility on [DATE] with a primary diagnosis of muscle wasting and atrophy. Section C- Cognitive Patterns of the admission MDS dated [DATE] revealed that the resident had a BIMS score of 11 out of 15 indicating that she was moderately impaired. On 10/22/21 at 2:49 p.m., the Activities Director reported that the concerns related to cold food was brought up in the Resident Council Meeting multiple times. He stated that the Dietary Manager attended the meeting when concerns were mentioned. On 10/22/21 at 3:09 p.m., the Dietary Manager stated she only had one complaint related to cold food from Resident #46. She stated that test trays were done once per month as a part of their monthly audits. The Dietary Manager stated that this process was in place prior to receiving the complaints related to cold food. She stated when they do the test tray, they follow the cart to the floor. The test tray is placed behind the resident's tray that had the complaint to see if there was a drop in the temperature. There were no concerns when the audits were conducted. She confirmed that concerns were brought up in the Resident Council Meetings related to cold food during the meetings she attended. She confirmed that she had only done audits in an attempt to resolve the concern. On 10/22/21 at 4:01 p.m., the Social Services Director (SSD) confirmed that she had not received any grievances from the Resident Council. She stated that after a concern was voiced, a grievance should be filed, and a follow up should be done. She stated that a grievance should be resolved within five days. The policy and procedure Grievance/Concern Management effective February 2021 revealed that the following: 12. Complete a concern report investigation with summary and conclusion. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105176 If continuation sheet Page 7 of 14 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 10/22/2021 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure side effects and/or behavioral monitoring with the use of psychotropic medications for two (Resident #43 and Resident #98) of five sampled residents. Findings include: On 10/20/21 at 10:43 a.m., Resident #43 was observed seated in her room in a wheelchair. Resident #43 was able to answer questions related to care and services in the facility. The resident stated she had been in the facility for several months. The resident appeared clean, dry and had no signs of distress or unusual behaviors noted during the interview. Resident #43 stated she was very sick with COVID last year and that started her decline. On 10/21/21 at 1:00 p.m., Resident #43 was observed in room resting quietly. The resident had no signs of distress, and no behaviors were observed. A review of the medical record for Resident #43 indicated the resident was admitted to the facility on [DATE] with diagnoses including anxiety and major depressive disorder. A review of the physician order sheet for Resident #43 revealed an order for Cymbalta capsule delayed release particles give 60 mg by mouth one time a day for depression. A review of the comprehensive care plan for Resident #43 revealed a focus area for Psychotropic Medications as follows: Resident #43 uses psychotropic medications: antidepressant to manage mod/behavior/depression initiated on 5/11/2021. Goal: Will have no side effects of psychotropic medications. Participate in activities of choice. Interventions: Administer medications as ordered. Observe/document for side effects and effectiveness; Anti-depressant observe/document for potential side effects may include dizziness, drowsiness, diarrhea, dry mouth, urinary retention, suicidal ideation, orthostatic hypotension. A review of the October 2021 Medication Administration Record (MAR) for Resident #43 revealed no monitoring for side effects was completed by nursing for the resident. On 10/20/21 at 10:53 a.m., Resident #98 was observed sleeping soundly in the bed. There were fall mats observed on the floor and the resident had no signs of distress, or any behaviors noted. A review of the medical record revealed Resident #98 was admitted to the facility on [DATE] with a diagnosis of insomnia. A review of the physician order sheet for Resident #98, revealed an order for Temazepam capsule 30 mg give one capsule by mouth every 24 hours as needed for insomnia. A review of the comprehensive care plan for Resident #98 revealed a focus area for Psychotropic medications as follows: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105176 If continuation sheet Page 8 of 14 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 10/22/2021 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 0758 Level of Harm - Minimal harm or potential for actual harm [Resident #98] uses psychotropic medications antidepressant and hypnotic to manage mood/behavior//depression/insomnia initiated on 7/14/21. Goal: Improve sleep pattern, participate in activities of choice, will have no side effects of psychotropic medication. Residents Affected - Few Interventions: Administer medications as ordered. Observe/document for side effects and effectiveness; Anti-depressant observe/document for potential side effects may include dizziness, drowsiness, diarrhea, dry mouth, urinary retention, suicidal ideation, orthostatic hypotension. Hypnotic observe/document for potential side effects may include dizziness, daytime drowsiness, headache, lethargy, anxiety, irritability, amnesia, sleep walking, sleep eating, palpitations, nausea, vomiting, constipation. A review of the October 2021 Medication Administration Record (MAR) for Resident #98 revealed no behavior monitoring was completed by nursing for the resident. On 10/21/21 at 5:01 p.m. Resident #98 was observed lying in his bed sleeping. There were no signs of distress. On 10/22/21 at 12:00 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated that nursing was responsible for implementing side effects and behavior monitoring for all psychotropic medications. She stated, each morning during the morning clinical meeting, all orders were checked for any new medications which might require side effects and behavior monitoring. When a psychotropic medication was identified, the team would assure the side effects and behavior monitoring was in place for the medication. The DON indicated that the nursing staff were also able to initiate side effects and behavior monitoring when they place a new order for a psychotropic. The DON indicated the initiation of the order was not a pharmacy process. When asked to review the side effects and behavior monitoring records for Resident #43 and Resident #98 the DON confirmed no side effects monitoring was in place for Resident #43 and no behavioral monitoring was in place for Resident #98. She stated she would correct the records immediately. On 10/22/21, an interview was conducted by phone with the Clinical Pharmacist for the facility. She confirmed that side effects monitoring should be in place for Resident #43 for use of Cymbalta. The Clinical Pharmacist stated the facility did not do behavioral monitoring for hypnotics like Temazepam. A policy was requested with the resident records for psychotropic medications but was not received. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105176 If continuation sheet Page 9 of 14 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 10/22/2021 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 Based on observation, record review, and interview, the facility did not ensure a medication error rate of less than 5%. During the medication pass observation, there were twenty five opportunities with six errors resulting in a 24% medication error rate for two (Residents #63 and #35) of five residents observed. Residents Affected - Few Findings included: On 10/21/21 at 9:00 a.m. medication administration was observed with Staff A, RN with Resident #63. The resident had an order for [brand name] Lidocaine Patch 4% apply to bilateral knees topically one time a day for non-acute pain. The nurse applied the patch to the residents lower back. On 10/21/21 at 9:13 a.m. Staff A, RN passed medications to Resident #35. The resident had current orders for and was given the following medications: Cinacalcet give 30 mg (milligrams) by mouth one time a day for nutritional support Ferrous Sulfate 325 mg give 1 tablet by mouth one time a day for nutritional supplementation Furosemide Tablet give 40 mg by mouth one time a day for edema Hydralazine tablet 10 mg give 1 tablet by mouth three times a day for HTN (Hypertension) The resident had the following order, but only received a half dose (6.25 mg): Coreg tablet (carvedilol) give 12.5 mg by mouth two times a day for HTN The resident had current orders for the following medications, that were not distributed, but marked as given: Cholecalciferol give 1000 units by mouth one time a day for nutritional supplementation Spironolactone Tablet give 25 mg by mouth one time a day for edema hold for SBP (systolic blood pressure-top number) <110 DBP (diastolic blood pressure-bottom number) <60 HR (heart rate) <60 Voltaren gel 1% (diclofenac sodium) Apply to both knees topically two times a day for arthritis The resident was administered the following medication, which was not on their current order set: Clopidogrel 75 mg On 10/21/21 at 2:21 p.m., in an interview with Staff A, RN, she said that creams and patches are usually treatments, but if they are on the MAR (medication administration record), then they are considered medications. I will ask the DON (director of nursing) to make sure, but that is what I think it is. If I make a medication error or give a medication that doesn't belong to a resident, then I would fill out an incident report, call the physician, call the family, tell the resident, and then monitor them for any side effects. When I pass medications, I pull the medication, compare it to the computer, make sure that the resident is the right resident, you know, make sure of the 5-rights of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105176 If continuation sheet Page 10 of 14 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 10/22/2021 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 passing medications. Level of Harm - Minimal harm or potential for actual harm On 10/21/21 at 2:22 p.m., the DON confirmed that if a medication is on the MAR it is considered a medication. Residents Affected - Few On 10/22/21 at 10:44 a.m., in an interview with the DON, she said, I'm going to do some training and education with the nurses. I'm going to do some spontaneous medication passes. I expect the nurses to follow current physician orders and notify them if a medication is missing and unable to be given. When giving a wrong medication, they (the nurses) must do a medication error report and observe the resident for possible side effects. If a medication is not ordered, they shouldn't give it. We have to call the physician and let them know what happened as soon as the error is discovered. On 10/22/21 at 3:15 p.m., an interview with the facility's Consultant Pharmacist was obtained my phone. She said that it was her expectation that the nurse followed the current physician orders when passing medications. In a policy given by the facility titled Medication Preparation dated 09/18 under procedures step 3 reads Prior to administration, review and confirm medication orders for each individual resident on the medication administration record. Compare the medication and dosage schedule on the residents MAR with the medication label. If the label and MAR are different, and the container is not flagged indicating a change in directions, or if there is any other reason to question the dosage or directions, the prescriber's orders are checked for the correct dosage schedule. In the same policy under Medication Administration step 1 reads Medications are administered in accordance with written orders of the prescriber Step 9 reads: Verify medication is correct three (3) times before administering the medication. A. When pulling a medication package from med cart. B. When dose is prepared. C. Before dose is administered. In the same policy under Documentation step 2 reads IF a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time .the space provided on the front of the MAR for that dosage administration is initialed and circled FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105176 If continuation sheet Page 11 of 14 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 10/22/2021 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and policy review, the facility did not ensure that a refrigerated controlled substance was secured in a separately locked, permanently affixed container on one of three units. Findings included: On 10/21/21 at 4:29 p.m., Staff B LPN (Licensed Practical Nurse), entered the medication storage room on Unit 1 to get a medication from the refrigerated emergency drug kit (EDK). He pulled out an opaque plastic container with a clear top that measured approximately 7-inches by 11-inches from the refrigerator. On top of this plastic container, attached to one of the corners by hook and loop fastener tape, was a small clear plastic container about the size of a pack of playing cards. When the nurse was asked what the small clear plastic container had in it, and he said Ativan (Lorazepam). Staff B, LPN was asked to count how many vials of medication was in the small clear plastic container, and he answered four . Upon further inspection, it was noted that 4-2 ml vials of Lorazepam were inside of the small clear plastic container. Staff B, LPN confirmed that the small container was only secured to the larger container by a hook and loop tape system. At 4:31 p.m., the Director of Nursing (DON) confirmed that the container was unsecured Lorazepam, and that it should have been locked in the lock box inside of the refrigerator in the medication room. She said that as soon as the EDK came from pharmacy, the narcotics should be taken off the larger plastic container and placed in the metal lock box immediately. The DON had the Lorazepam put into the separately locked refrigerated container. On 10/22/21 at 3:15 p.m., in a phone interview with the facility's Consultant Pharmacist, she said that it was her expectation that narcotics be double locked. She said, I know that facility has a lock system, and it should have been in the lock system, not still attached to the insulin EDK. In a policy given by the facility titled Controlled Medication Storage under procedures, #4 reads Controlled medications requiring refrigeration are stored within a locked, permanently affixed box within the refrigerator. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105176 If continuation sheet Page 12 of 14 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 10/22/2021 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observations of meals, interview with residents and facility staff, and review of the facility's menu and materials on the facility's new diet, ( IDDSI - International Dysphagia Diet Standardization Initiative), the facility failed to ensure residents who were on mechanically altered diets received foods that had been correctly prepared to follow the IDDSI guidelines and ensure the foods were safe for two (Residents #60 and #22) of 41 residents identified as having physician orders for mechanically altered diets. Findings included: 1- On 10/19/2021 at 12:30 p.m., Resident # 60 was observed at lunch. She was observed to be sitting up in bed, with her over the bed table across her waist and her lunch tray accessible in front of her. She had been served a total of three, two scoops of fried rice with pork, broccoli and a wheat roll. The resident had inserted her fork into her roll and was holding the roll up like a flag. The roll looked to be a solid mass and was stable on the tines of the fork. When asked if she needed a knife to cut off a bite of it, she shook her head no and put the fork with the roll back down on her tray. The Dietary Manager (DM) was passing in front of the resident's room and was called in to look at the resident's lunch tray. When asked why she would have received three scoops of fried rice with pork, the DM reported she wasn't sure. The diet slip that lists the resident's diet order and any preferences or changes or deletions on the diet was noted to be available on the lunch tray. Review of the diet slip revealed the resident's diet was Regular, SB6 (small bites level 6)/Mech (Mechanical), Thin (liquids). The diet slip listed the two scoops of the sweet sour pork SBMM (soft bites minced & moist), plus one #8 scoop (1/2 cup) of fried rice, pureed. The individual scoop of fried rice was not pureed. All rice scoops were noted to contain rice that had separated into individual grains. The diet slip also listed a wheat roll slurried. The DM reported that the roll should be soft enough to press with the fork and break apart. When the roll that the resident had held aloft with her fork was pointed to, and the DM was asked why it was still a solid mass, the DM reported she would have to look into it. 2- On 10/21/2021 at 12:30 p.m., Resident #22 was observed in the dining room with an aide who was assisting her with her meal. The diet slip that accompanied the resident's lunch indicated her physician ordered diet was Regular, SB6 (small bites level 6)/Mech (mechanical), thin (liquids). The resident had been served small chunks of chicken in gravy, green beans that were soft and able to be mashed with a fork, and white rice. The diet slip indicated the rice was to be rice pilaf. A dinner roll was on the plate and when the aide tried to break it apart with the side of the fork, she was unable to do so. A cookie was on a small plate and it had been slurried, which the resident was able to pick up and even though it crumbled in her fingers she was able to put it into her mouth. 3- On 10/21/2021 at 1:00 p.m., while temperatures on the steam table were being monitored, the DM was asked about the slurried rolls. She demonstrated with tongs how the rolls had been placed into a deep aluminum steam table pan and thickened milk was poured over them to slurry them. She reported that the rolls should soak up the milk and be soft enough to break apart. She stabbed one of the rolls with the tongs and pushed it around the bottom of the pan. The slurried roll did not break up and she was not able to pull the tongs out of the slurried roll. During the observation of the steam table on 10/21/2021, the Regional Registered Dietitian confirmed that the cook had not added the seasoning mix to the rice to make rice pilaf. She confirmed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105176 If continuation sheet Page 13 of 14 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 10/22/2021 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 0805 residents were receiving plain white rice. Level of Harm - Minimal harm or potential for actual harm 4- On 10/22/2021 at 10:20 a.m., an interview was conducted with the facility's Registered Dietitian (RD) who confirmed the facility had made the decision to follow the IDDSI (International Dysphagia Diet Standardization Initiative) diet consistencies rather than follow the prior diet consistencies - regular, mechanical soft, and pureed. She reported she had received training from a Corporate RD, who also assisted in reviewing the diets and changes to be made in all the residents' diets. She reported that the Regional RD had provided training to the dietary aides and cooks. She also reported that the Speech Therapist reassessed all residents who had been on Mechanical Soft or Pureed diets to determine which diet would be appropriate for them from the new IDDSI plan. Residents Affected - Few The facility's RD reported that their roll-out date for the new diet and menu items was 10/04/2021. She confirmed that once the new diet and menus were introduced there had not been audits of the served meals. On 10/22 /2021 at 3:15 p.m., the Regional RD provided an example of a slurried roll and the consistency that it should attain prior to serving to a resident. The slurried dinner roll pulled apart and allow for easy chewing and swallowing. It did not have the consistency that was observed when the DM demonstrated the slurried roll to the surveyor during the tray line monitoring. It did not have the consistency that was observed on the two resident's lunch plates observed on 10/19/21 and 10/21/2021. The Regional RD described her process in slurrying the rolls which followed the recipe: slice the rolls in half horizontally and using a toothpick make multiple holes across the surface area. Combine 2% milk with a food thickener to make a slurry. Using 2 ounces of slurry per roll, pour one ounce of slurry onto a plate, place roll halves on slurry and pour remaining one ounce over roll, covering the entire surface area. The Regional RD provided a copy of the recipe. It was noted that during the lunch observation of the slurried rolls, the rolls had not been sliced in half or punctured with a toothpick to allow the slurry to saturate the roll. The Regional RD confirmed that the cook had not followed the recipe to slurry the rolls. The Regional RD also provided a recipe for a sauce to be used with the pureed rice to allow it to be safely consumed. Review of the IDDSI materials indicated that Rice requires a sauce to moisten it and hold it together. [NAME] should not be sticky or gluey and should not separate into individual grains when cooked and served. The Regional RD confirmed that the plain white rice should not have been served to residents on the SB6 diet without a thick sauce. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105176 If continuation sheet Page 14 of 14