Health inspection·January 24, 2024

F 0550 full weight bearing on right leg, and used a wheelchair for ambulation. Level of Harm - Minimal harm or potential for actual harm A review of Physician Orders, dated 11/27/2023, revealed physical therapy, occupational therapy five times per week for four weeks, admit to skilled unit, monitor left hip surgical site for signs and symptoms of infection, and restorative nursing as needed. Residents Affected - Few A review of the comprehensive care plan, dated 12/3/2023, revealed the following: Focus area for activities of daily living related to toileting. Resident is incontinent of bowel and bladder and is not a candidate for a toileting program. Intervention for toileting was an assist of one and to use bedpan/urinal. A review the progress notes for Resident #109 revealed the following: --Progress Note 12/18/2023 resident uses a manual wheelchair for ambulation, and resident is incontinent. --Progress note of 12/25/2023 resident is continent of his bladder and urine is clear yellow. --Progress notes from 12/26/23 to 1/21/2024 resident is continent of bladder and bowel. During an interview on 01/23/2024 at 11:00 a.m. with Resident #109 he stated he can tell when he has to use the urinal and when he has to have a bowel movement. He stated he only had one episode of bowel incontinence since his admission and it was on the first night in the facility. He stated the bedpan he was given was too small and no one had discussed his bowel and bladder concerns with him. During an interview on 01/23/24 at 11:37 a.m. Staff C, Registered Nurse (RN) stated the Resident #109 had not been incontinent that she was aware of, and the resident uses the urinal and a brief for bowel movements. During an interview on 01/23/24 at 11:44 a.m. Staff D, Staffing Coordinator/Central Supply stated there are two sizes of bed pans available, a small one and a larger one. She stated she was not aware of a policy on sizing the appropriate one for a resident. During an interview on 01/23/2024 at 1:30 p.m. the Interim Director of Nursing (IDON) stated the facility did not have a policy regarding use of bedpans and sizing for a resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105176 If continuation sheet Page 2 of 26 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 01/24/2024 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 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, interviews, and record review the facility failed to provide a clean, sanitary, and homelike environment for residents on one unit (#300) out of three units in the facility. Findings included: An observation was conducted on 1/21/24 at 10:19 a.m. of room [ROOM NUMBER]. The observation revealed a three-drawer dresser inside the bathroom with a missing drawer and on the floor next to the dresser was 2 gray water basins sitting on the floor. The over-bed table of the room was rusty and uncleanable. The vinyl baseboard near the closet was missing and the wallboard was broken. The wall near the entrance door was broken behind the baseboard. An observation on 1/21/24 at 10:45 a.m., was made of room [ROOM NUMBER]. An open area of approximately 3/4 inch was noted on the side of the wall air conditioning unit. The area was open to the outside and could be seen while standing in the resident room. The closet door track was rusty and unclean. An over-the-bed table located in the room was rusty and uncleanable. The toilet in the bathroom shared by room [ROOM NUMBER] and 304 did not have a tank cover and a plastic cup was sitting on the handrail in the bathroom containing 3 disposable razors and water. During the observation of room [ROOM NUMBER] on 1/21/24 at 10:48 a.m., Staff A, Licensed Practical Nurse/Unit Manager (LPN/UM), stated the razors should not be left in the bathroom and the toilet without a cover should not have been left like that way. Staff A stopped the Maintenance Director in the hallway and the Maintenance Director reported not knowing about the toilet tank cover and the expectation was for staff to notify him of any concerns. Staff A provided a copy of the Concierge Program Rounds form. The form revealed the concierge was to note any environmental issues such as: room odor, closet doors, bedside table, nightstand, chair, cubical curtains, and call lights. The form revealed, If another issue is identified that is not on this list, please write it on the back of this page. Include the room number. An interview was conducted on 1/21/24 at 10:55 a.m. with Staff J, Certified Nursing Assistant (CNA). Staff J stated she had shaved the resident and was coming back for the razors observed in the bathroom shared by room [ROOM NUMBER] and 304. The staff member stated the toilet tank cover had been reported awhile ago. An observation was made on 1/21/24 at 11:07 a.m., of room [ROOM NUMBER]. The bed mattress was noted to have a disintegrated vinyl backing. The mattress was uncleanable. An interview was conducted with Staff K, Certified Nursing Assistant (CNA), on 1/21/24 at 11:12 a.m. The staff member stated the resident who had personal items in room [ROOM NUMBER] had been sent to the emergency room and had not been in the building since Saturday. On 1/22/24 at 12:00 p.m., the Maintenance Director and Staff D, Staffing Coordinator, were observed moving the bed, including the uncleanable mattress, from room [ROOM NUMBER] to room [ROOM NUMBER]. The Maintenance Director stated room [ROOM NUMBER] was going to be closed for the safety of the resident. Staff D stated the mattress should have been taken out of service before today or prior to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105176 If continuation sheet Page 3 of 26 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 01/24/2024 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 when the resident who was in room [ROOM NUMBER] had been taken to the hospital. Level of Harm - Minimal harm or potential for actual harm An observation on 1/21/24 at 12:39 p.m., revealed a three-drawer dresser in room [ROOM NUMBER] next to bed A with a drawer sitting on the floor and missing the top and bottom drawer. Residents Affected - Some An observation of room [ROOM NUMBER] on 01/21/24 at 12:42 p.m., revealed a rusty over-the bed table and an uneven transition between the resident's room and bathroom. The room smelled of very strong urine. An observation on 1/21/24 at 1:15 p.m. of the bathroom shared by room [ROOM NUMBER] and 313 was missing the toilet paper bracket, one bracket was attached to the wall under the handrail. The toilet paper roll was sitting on the handrail. An observation of room [ROOM NUMBER] on 1/22/24 at 9:00 a.m. revealed a portion of vinyl baseboard missing revealing crumbling wallboard. The observation showed a portion of wall behind the baseboard was cracked. An interview was conducted on 1/24/24 at 12:00 p.m. with the Account Manager for Housekeeping/Laundry. She stated the facility had identified rusty overbed tables and staff were steaming them to clean. The Manager stated the 300 hall had been completed. A tour of the 300 hall was conducted on 1/24/24 at 11:59 a.m., with the Maintenance Director. The Maintenance Director reported being at the facility for 4 months and was the only person in the maintenance department. The tour included room [ROOM NUMBER]. The Director stated the gap between the wall and air conditioning unit should not be that way, the broken plaster in room [ROOM NUMBER] should be fixed, and the toilet paper holder in the bathroom of 312 and 313 had been fixed once before. The Director observed one of the rusty over bed tables and agreed it was not only rusty but dirty with an unknown substance. The Director confirmed the uneven transition between the floor in room [ROOM NUMBER] and the bathroom should be fixed. He reported removing the dresser in room [ROOM NUMBER] and confirmed it should have been removed prior to the observation on 1/21/24. Immediately following the tour of the 300 unit on 1/24/24, a request was made for a policy regarding the maintenance of the facility. The facility did not provide the policy by the completion of the survey. (Photographic evidence was obtained). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105176 If continuation sheet Page 4 of 26 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 01/24/2024 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) for four residents (#51, #236, #72, #115) out of six sampled residents, were revised for accuracy related to diagnoses. Findings included: 1) A review of Resident #51's admission Record showed the resident was admitted on [DATE] and re-admitted on [DATE]. The record showed diagnoses of unspecified Alzheimer's disease with an onset date of 8/3/21, unspecified dementia unspecified severity with other behavioral disturbance, mild single episode major depressive disorder, delusional disorders, and other insomnia. Review on 1/22/24 at 9:51 a.m., of Resident #51's admission Record showed Alzheimer's disease was the primary diagnosis. Review of Resident #51's PASRR, dated 3/16/23, showed the resident had a mental illness (MI) of depressive disorder and did not reveal the resident's delusional disorder. The PASRR did not reveal the resident had a primary diagnosis of dementia or related neurocognitive disorder (Alzheimer's disease). Section II question 7 of the PASRR showed the resident had validating documentation to support the dementia or related neurocognitive disorder. The PASRR revealed the resident did not have a diagnosis or suspicion of Serious Mental Illness or Intellectual disability and a Level II was not required. On 1/22/24 at 4:20 p.m., the Social Service Director (SSD) reviewed Resident #51's diagnoses and PASRR. She confirmed it did not include all the resident's diagnoses and should be revised. 2) Review of Resident #236's admission Record showed the resident was admitted on [DATE] with diagnoses not limited to unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, unspecified Bipolar disorder, unspecified depression, and unspecified recurrent major depressive disorder. Review of Resident #236's PASRR, dated 1/17/24, did not show the resident had any mental illness (MI) or intellectual disability (ID) diagnoses and a Level II was not required. A request was made to the Nursing Home Administrator (NHA) on 1/22/24 at 2:30 p.m. for a copy of Resident #236's PASRR. During an interview on 1/22/24 at 4:11 p.m., the SSD stated a revision of Resident #236's PASRR was done on 1/22/24. She reported working on PASRR's for the last hour and a half. She stated she goes through new admissions on Mondays and fixes them (PASRR's) then if needed. The SSD reported usually PASRR's come into the facility a couple hours before the admission or come in with the new admission, and are reviewed during the morning meetings. On 1/22/24 at 5:45 p.m., the SSD provided a PASRR Level I submission, dated 1/22/24 at 3:48 p.m., and a document showing Resident #236's PASRR Level I was resubmitted at 4:43 p.m. on 1/22/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105176 If continuation sheet Page 5 of 26 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 01/24/2024 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3) Resident #72 was admitted on [DATE] with diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, unspecified psychosis not due to a substance or known physiological condition, other specified depressive episodes, and Bipolar disorder. Review of Resident #72's PASRR Level I Assessment, dated 02/21/23, revealed a qualifying diagnosis of Bipolar disorder and no PASRR Level II was required. Review of Resident #72's medical record revealed a new diagnosis of generalized anxiety disorders documented on 05/25/23 and the resident was not assessed for PASRR Level II. Section I Active Diagnosis of the significant change in status Minimum Data Set (MDS), dated [DATE], showed Resident #72 had the following psychiatric/mood disorders: anxiety disorder, depression, Bipolar disorder, and psychotic disorder. On 01/22/24 at 4:26 p.m., the Social Services Director (SSD) confirmed Resident #72's current diagnoses were not reflected on the PASRR Level I. She stated a PASRR Level II should have been submitted. 4) A review of admission record, dated 08/11/2023, revealed Resident #115 was admitted on [DATE] with diagnoses including unspecified dementia, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, adult failure to thrive, other symptoms and signs involving cognitive functioning and awareness, adjustment disorder with mixed disturbance of emotions and conduct, and dementia in other disease classified elsewhere severe with other behavioral disturbance. A review of Pre-admission Screening and Resident Review (PASRR) dated 08/10/2023, revealed a documented history of secondary diagnosis related to neurocognitive disorder (including Alzheimer's disease) and the primary diagnosis is a serious mental illness or intellectual disability. In section II: Other indications for PASRR screen decision-making, continued: Does the individual have validating documentation to support the dementia or related neurocognitive disorder (including Alzheimer's disease)? The response was yes - medical/functional history prior to onset. A review of Minimum Data Set (MDS) Quarterly None PPS Section C Cognition, dated 11/17/2023 revealed a Brief Interview for Mental Status (BIMS) score of 2, indicating severe cognitive deficit. A review of the medical record did not include a Level II PASRR determination. The facility did not provide a Level II PASRR determination. During an interview on 01/22/24 04:29 pm with the Director of Social Services (DSS) she stated the PASRR Level I for Resident #115, which indicated a Level II PASRR should have been completed was not uploaded into the medical record, and she did not have any additional records. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105176 If continuation sheet Page 6 of 26 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 01/24/2024 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to complete the Preadmission Screening and Resident Review (PASRR) Level II assessment for a qualifying mental health diagnosis for two residents (#6 and #97) of six residents sampled. Residents Affected - Some Findings included: Review of the admission Record showed Resident #6 was admitted on [DATE], and readmitted on [DATE], with diagnoses of dementia without behavioral disturbance, anxiety disorder, adjustment disorder with mixed anxiety and depressed mood, mood disorder, and other comorbidities. Review of Resident #6's PASRR Level I Assessment, dated 02/24/2023, showed a qualifying mental health diagnosis marked in section I A. for anxiety. Section II, (7) is marked yes for having validating documentation to support the dementia . and documentation should accompany the Level I PASRR screen . There is no evidence a Level II evaluation was submitted. During an interview on 01/22/2024 at 04:11 PM, the Social Service Director (SSD) confirmed responsibility for the completion and oversite of the PASRR process. The SSD stated the PASRR Level I for Resident #6 was inaccurate, and a new PASRR should be completed for an evaluation of a Level II PASRR. Review of the admission Record showed Resident #97 was admitted on [DATE] with diagnoses of psychotic disorder with delusions, adjustment disorder, dementia, major depressive disorder, and other comorbidities. Review of Resident #97's PASRR Level I Assessment, dated 03/16/2023, showed a qualifying mental health diagnosis marked in section I A. for depressive disorder and other: psychotic disorder with delusions, adjustment disorder with mixed disturbance, unspecified behavioral and emotional disorders, currently receiving services for MI and receiving Lexapro, Seroquel. Section (7) is marked yes for having validating documentation to support the dementia . and documentation should accompany the Level I PASRR screen. There is no evidence a Level II PASRR evaluation was submitted. During an interview on 01/22/2024 at 04:11 PM, the Social Service Director (SSD) confirmed responsibility for the completion and oversite of the PASRR process. The SSD stated the PASRR Level I for Resident #97 was inaccurate, and a new PASRR should be completed for an evaluation of a Level II PASRR. Review of the facilities policy and procedures titled topic PASRR requirements Level I and Level II - Florida, with effective date February 2021 revealed the following: Policy: Pre-admission Screening and Resident Review (PASRR) pre-admission screening for mental illness and intellectual disability is required to be completed prior to admission to a nursing home. The screening is reviewed by admissions to ensure appropriate placement in the least restrictive environment and to identify any specialized services the applicant may need. PASRR screening applies to all new admissions into a Medicaid certified nursing facility regardless of payer source . Procedure: . 2. Social Services or Registered Nurse (RN) will review to determine if a Serious (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105176 If continuation sheet Page 7 of 26 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 01/24/2024 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Mental Illness (SMI) and Intellectual Disability (ID) or both exist while reviewing the PASRR form. The existence of either, or both, conditions trigger the requirement for Level II review and will be provided to the appropriate state agencies by the Social Service Director upon admission. The Social Services Director/Nursing Administration will review for completion and accuracy during the clinical meeting process. Recommendations will be implemented into the resident's plan of care then the document will be filed in the resident's record . PASRR Level II . 3. Level II PASRR must be completed if the below are listed but not limited to: .the resident has a primary or secondary diagnosis of dementia or related neurocognitive disorder, and a suspicion, or diagnosis of, SMI, ID, or both . Event ID: Facility ID: 105176 If continuation sheet Page 8 of 26 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 01/24/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to review and revise the resident centered care plan related to behaviors for one resident (#82) of five residents sampled for comprehensive care plans. Findings included: A review of Resident #82's admission Record showed the resident was originally admitted on [DATE] and re-admitted on [DATE]. The record showed diagnoses not limited to not elsewhere classified anoxic brain damage, unspecified intractable epilepsy with status epilepticus, and adult failure to thrive. A review of Resident #82's medical record showed a completed Hospital Transfer Form dated 1/19/24. The form showed the reason for transfer was the Replacement of G-tube. The form revealed the resident was sent to an acute care hospital on 1/19/24. On 1/23/24 at 1:49 p.m. Resident #82 was observed lying in bed, bilateral legs were contracted at bilateral knees, hands held near the head region, and the resident remained nonverbal but followed this writer and Staff C, Registered Nurse (RN) with eyes without moving head. Staff C reported the resident had been sent out on Monday or maybe Friday to have the Percutaneous Endoscopic Gastrostomy (PEG)/G-tube replaced. An observation was conducted with Staff C of cleaning the resident's g-tube. The area around the insertion point was open to air, clean, without redness or drainage. The staff member reported the resident often pulls the g-tube out. An interview was conducted with the Nurse Practitioner (NP) on 1/23/24 at 2:29 p.m. The NP reported Resident #82 frequently pulls out the G-tube. The NP stated sometimes they will find the balloon at skin level, and often (staff) finds the G-tube lying beside the resident in bed. A review of Resident #82's Comprehensive Care Plan revealed the resident had been noted With the following behaviors: will place parts of her gown in her mouth and is resistive to removal. Will grab and pull at clothing, sheets, (and) g-tube. A review of the item changes related to the behavioral care plan showed, Will grab and pull at clothing, sheets, (and) g-tube was added on 1/24/24. An interview was conducted with the Minimum Data Set (MDS) Coordinator on 1/24/24 at 9:17 a.m. The Coordinator stated the nursing team had come to her in the morning (1/24/24) and informed her the resident had been seen, as she had also witnessed, of Resident #82 pulling at G-tube and gown, so the care plan had been revised to add G-tube to the behaviors, This morning. The Coordinator stated that if it (pulling at G-tube) was a behavior it would be discussed in morning meeting and she would be told to add it to the care plan or nursing could have added it. An additional interview was conducted with the Coordinator on 1/24/24 at 10:00 a.m., she confirmed she had Added this line today then read Will grab and pull at clothing, sheets, g-tube. During an interview on 1/24/24 at 9:28 a.m., Staff F, Director of Nursing (DON) stated the care plan should have included the behavior of Resident #82 to pull on G-tube. The staff member reported feeling the resident was constantly being sent to the hospital (for G-tube replacement). A review of the policy entitled Care Plan Interdisciplinary Plan of Care from Interim to Meeting, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105176 If continuation sheet Page 9 of 26 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 01/24/2024 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 0657 revised 9/23, showed the following: Level of Harm - Minimal harm or potential for actual harm The facility shall support that each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility shall address care issues that are relevant to individual residents, to include, but may not be limited to monitoring resident condition and responding with appropriate interventions. The comprehensive care plan is an interdisciplinary communication tool. It includes measurable objectives and time frames and describes the services that are to be furnished to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being. The care plan is reviewed and revised periodically, and the services provided or arranged are consistent with each resident's written plan of care. Daily updates to care plans are added by a member of the interdisciplinary team (IDT) at the time the change is implemented, the intervention is needed, or other care plan revision is indicated. Accuracy of the care plan is validated by the IDT during the daily clinical meeting. The comprehensive care plan describes or includes adequate information provided to make informed choices regarding treatment. The care plan meeting include nursing which will Review current diagnosis, tests, or procedures, treatments (wounds, rashes, etcetera (etc.). discuss current interventions and risk of further breakdown if applicable, recent or pending referrals, Physician Consults, Restorative, medications, pain management plan, behavioral management plan, special needs, risk of falls and current interventions, and recent falls or other issues (informed consents, isolation, etc.). Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105176 If continuation sheet Page 10 of 26 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 01/24/2024 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to provide activities of daily living (ADL) for one resident (#18) out of four residents sampled for ADL care related to personal hygiene and bathing. Residents Affected - Few Findings included: 1) An observation on 01/21/24 at 11:05 AM revealed Resident #18 lying in his bed. The resident was able to verbalize his name and introduce himself. Closer observation of the resident revealed the resident was noted with stubbly white facial hair and long fingernails. The resident was asked if he preferred facial hair and he stated, No, I need a shave, you gonna shave me? An observation of Resident #18 on 01/22/24 at 10:07 AM revealed the resident resting in bed. The resident was noted with his face still unshaven with gray stubbly hair covering his face and chin. The resident's fingernails were noted to still be elongated on his bilateral hands. The resident reported he was still waiting to be shaved and does not like the hair on his face and would like for his nails to be shorter. A review of the significant change of status Minimum Data Set (MDS), dated [DATE], revealed the resident required extensive assist of one person for personal hygiene. A review of the Comprehensive Care Plan related to ADL's with a start date of 3/28/13 revealed the resident Has an ADL Self Care Performance Deficit as evidence by: Cannot complete ADL tasks independently and requires individualized interventions because weakness, bilateral BKA [below knee amputation], fatigue. Review of the interventions revealed they included: Resident is total dependent upon staff for ADL's. An observation of Resident #18 on 01/22/24 at 02:56 PM revealed the resident was still unshaved and his fingernails were still elongated. The resident reported he would like to be shaved and his fingernails cut. The resident asked if he could get shaved now. An interview on 01/22/24 at 03:00 PM with Staff A, Licensed Practical Nurse (LPN) revealed she was assigned to the carts for the 100 hall. She reported typically staff are made aware of resident ADL needs from the [NAME] system. She reported Certified Nursing Assistant (CNA)'s are responsible for shaving the resident as needed or requested. She reported for nail care if the resident is diabetic the nurse will cut the fingernails. She stated if the resident is not diabetic the CNA should make the activities department aware and activities would cut the fingernails. An interview on 01/22/24 at 03:03 PM with Staff B, CNA revealed she is assigned to the middle 100 hall. She reported she would know if a resident needed to be shaved and if nail care is needed by visualizing the resident daily during care. An observation and interview on 01/22/24 at 03:05 PM of Resident #18, with Staff F, DON, Staff A, LPN, and Staff B, CNA present, the resident reported he would like to be shaved now and would also like his nails cut. The resident asked if he could get the razor so he could shave himself. Staff F, DON encouraged the resident to allow the staff to shave him and the resident was agreeable. Staff F, DON and Staff A, LPN confirmed the resident was in need of a shave and his fingernails were long and needed to be cut. At this time, policies related to ADL's, grooming, nailcare, and personal care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105176 If continuation sheet Page 11 of 26 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 01/24/2024 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 0677 were requested of Staff F, DON. Level of Harm - Minimal harm or potential for actual harm On 01/23/24 at 09:57 AM an interview with Staff F, DON revealed the facility does not have a policy on ADL's but they follow the CNA job description. The CNA job description was requested. A policy on grooming was also requested at this time. Residents Affected - Few On 01/23/24 at 01:30 PM with Staff M, Interim DON revealed the facility does not have a policy on grooming and the CNA job description would be provided. The facility did not provide the CNA job description as requested by the end of the survey. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105176 If continuation sheet Page 12 of 26 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 01/24/2024 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to provide treatments and care in accordance with professional standards of practice as evidence by 1) failure to assess and treat a wound for one resident (#51) out of two sampled for skin conditions, 2) failure to document and treat a change in condition according to facility policy for one resident (#82) out of two residents sampled for change in condition, and 3) failure to maintain a midline intravenous catheter as ordered for one resident (#41) out of one sampled for intravenous access. Residents Affected - Some Findings included: 1) On 1/21/24 at approximately 10:18 a.m., Resident #51 was observed sitting across from the nursing station of the secured unit with other residents. The observation showed a brown adhesive dressing on the left toe. The dressing appeared to be undated. On 1/21/24 at 10:22 a.m., Staff A, Licensed Practical Nurse/Unit Manager (LPN/UM) placed blue non-slip socks on Resident #51. The staff member reported not knowing why the resident had a dressing on the left middle toe and would have to check but podiatry was in the building last week. Staff A removed the dressing and stated she was going to check (the area) later and confirmed the dressing was not dated. The observation revealed an area on the tip of the left middle toe with a scant amount of bright red drainage near the top of the toe nail. The staff member called the Director of Nursing (DON) informing her that the dressing was not one used by the facility and reported the DON confirmed podiatry had been in the facility last week. The staff member reviewed the resident's clinical record located on the unit and stated the last documentation from the podiatry provider was from November 2023. Review of Resident #51's admission Record showed the resident was originally admitted on [DATE] with a diagnosis of unspecified Diabetes Mellitus due to underlying condition with Diabetic neuropathy. The record included additional diagnoses of Type 2 Diabetes Mellitus without complications (onset 8/9/22), unspecified Alzheimer's disease, Essential (primary) hypertension, and adult failure to thrive. A review of Resident #51's Podiatry notes, dated 1/17/24, revealed mycotic nails of right foot, have approximately 2 millimeter (mm) thickness of sublingual debris, and the mycotic nails are thickened, yellowed, causing pain. The note showed there was hyperkaratotic tyloma at the medial plantar left hallux with pain. The provider documented the removal of the hyperkaratotic lesion and all affected nails were debrided to reduce length and thickness, which included nails 1-5 on bilateral feet by the use of manual nippers and an electric grinder. The note showed there were no complications and the patient tolerated well. A review of Resident #51's Medication and Treatment Records for January 2024 did not reveal an order for a dressing to be applied to the resident's left toe. The Medication Administration Record showed the resident received oral and injectable medications for Diabetes Mellitus. A review of Resident #51's progress notes, dated 1/17/24 at 6:34 a.m. to 1/21/24 at 10:52 a.m. (30 minutes after observation with Staff A), did not show staff had noted the area or a dressing had been applied on the resident's left middle toe. The Skin/Wound note, dated 1/21/24 at 10:52 a.m., showed Staff A had noted a dressing to the resident's 3rd digit on left foot and when the dressing had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105176 If continuation sheet Page 13 of 26 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 01/24/2024 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 0684 been removed The toe nail had blood tinge at the top. Level of Harm - Minimal harm or potential for actual harm A review of Resident #51's Quarterly Minimum Data Set (MDS), dated [DATE], showed the resident's Brief Interview of Mental Status score was 3/15, indicative of severe cognition impairment. The MDS did showed the resident had a diagnosis of Diabetes Mellitus. Residents Affected - Some A review of the Certified Nursing Assistant (CNA) plan of care (Kardex) for Resident #51 showed staff were to Observe extremities for changes in extremities, to monitor for major and minor bleeding, and Report changes in discoloration area, pain location/type frequency/intensity, and Skin Observation. A review of the CNA documentation of Skin Observation from 12/26/23 to 1/22/24, showed the aides identified twice (1/8/24 and 1/20/24) discoloration. The resident's progress notes did not show the discoloration on 1/20/24 had been documented or if the nurse had assessed the area of discoloration. A review of Resident #51's Skin Check Weekly and as needed (PRN) evaluation, showed on 1/17/24 at 2:27 p.m., the resident had No New Areas of Skin Impairment. The Skin Check Weekly and PRN evaluation, dated 1/22/24 at 11:07 a.m., did not identify any new areas of skin impairment. A review of Resident #51's care plan revealed the following focuses and interventions: - Has an Activities of Daily Living (ADL) self care performance deficit and requires one-person assist for personal hygiene and dressing. - At risk of developing a wound. The interventions showed staff were to review with the resident/family/caregivers causes of skin breakdown. - Has Diabetes Mellitus as evidence by Type 2 Diabetes. The interventions showed staff were to observe/document/report to physician as needed the signs/symptoms of hypoglycemia and hyperglycemia. - Is on Aspirin. The interventions revealed staff were to provide a safe environment, assist with transfers/mobility as needed, and to protect extremities from trauma to lessen the possibility of bleeding/injury. The staff were to observe extremities for changes in extremities. A review of the policy entitled Weekly and PRN Skin Check, effective October 2021, revealed the following: Weekly and prn Skin Check was used to document skin condition throughout the Resident/Patient's stay in the facility and the nurse would conduct a weekly skin check and/or a prn check when applicable as a proactive measure to identify impairment or suspected impairment timely to reduce the risk of further decline in skin integrity. If a new area of impairment is identified during or between scheduled checks, it soul be documented on the weekly and prn skin check and the appropriate skin grid initiated depending on the cause. The procedure showed If a new area is identified the appropriate skin grid should be initiated within 8 hours. A review of the document titled The Centers of Disease Control and Prevention (CDC) guidance Diabetes and Your Feet, last reviewed April 11, 2023, showed the following: If you have diabetes, here's a way to keep standing on your own feet: check them every day - even (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105176 If continuation sheet Page 14 of 26 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 01/24/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some if they feel fine - and see your doctor if you have a cut or blister that won't heal. The guidance revealed there was a lot to manage with diabetes: checking blood sugar, eating healthy, being active, taking medications, doctor appointments and With all that, your feet might be the last thing on your mind. But daily care is one of the best ways to prevent foot complications. The CDC showed tips on how to prevent feet complications which included: check your feet every day for cuts, redness, swelling, sores, blisters, corns, calluses, or any other change to the skin or nails, wash your feet every day, dry completely, and apply lotion to the top and bottom, and never go barefoot - always wear shoes and socks or slippers to avoid injury. Most people with diabetes can prevent serious foot complications. Regular care at home and going to all doctor's appointments are your best bet for preventing foot problems (and stopping small problems from becoming serious ones). 2) A review of Resident #82's admission Record showed the resident was admitted on [DATE]. The record revealed the resident's diagnoses included anoxic brain damage not elsewhere classified, unspecified intractable epilepsy with status epilepticus, cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery, cachexia, unspecified protein-calorie malnutrition, and adult failure to thrive. A review of Resident #82's progress notes, dated 1/19/24, revealed the first note was a Hospital Transfer Evaluation Summary, documented at 5:57 a.m., which showed the resident was being transferred to an acute care facility To get G-Tube replaced. The note included the following vital signs and the date they were obtained: Blood pressure (BP): 105/64, obtained 11/4/23 at 7:15 a.m. Pulse: 86, obtained 11/4/23 at 7:14 a.m. Respiration Rate: 17, obtained 11/4/23 at 7:13 a.m. Temperature: 97.1, obtained 11/4/23 at 7:14 a.m. Oxygen (O2) saturation: 98.0%, obtained 2/23/23 at 2:30 p.m. Pain: 0, obtained 1/19/24 at 1:47 a.m. The document showed the resident's blood pressure, pulse, respiration rate, and temperature were obtained 10 weeks and 6 days prior the transfer on 1/19/24, the oxygen saturation was obtained 11 months prior to the transfer, and the pain level was obtained 4 hours prior to the unplanned transfer. The note revealed the resident's guardian was notified of the transfer but was not aware of the clinical situation and did not show the primary care physician was notified of the transfer. A review of the Hospital Transfer Evaluation Summary did not reveal why the gastrostomy tube (G-tube) required replacement, and the record did not include any other progress note completed at the time of the evaluation revealing the reason for the replacement (clogged, dislodged, broken), the condition of the resident or the status of the G-Tube insertion site. A review of the progress note, dated 1/19/24 at 6:20 a.m., revealed Transfer was told to be canceled due to new policy on G-tube insertion. Resident remained in the facility for care. The note did not show the physician or guardian was notified the transfer was canceled due to a new policy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105176 If continuation sheet Page 15 of 26 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 01/24/2024 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 0684 A review of Resident #82's progress notes on 1/19/24 revealed the following in their entirety: Level of Harm - Minimal harm or potential for actual harm - 1/19/24 at 8:47 a.m., Resident sent to emergency room to replace G-tube. Doctor and patient manager (name) notified. Residents Affected - Some - 1/19/24 at 10:14 a.m., Resident send hospital. - 1/19/24 at 2:08 p.m., Resident just returned from (acute care facility) emergency room (ER) via stretcher by transport services. GTube placement was verified via contrast and contrast appeared in the correct space in stomach and she was sent back here. An interview and observation of Resident #82 was conducted on 1/23/24 at 1:49 p.m. with Staff C, Registered Nurse (RN). The staff member cleaned the GTube site during the observation. Resident #82 remained non-verbal throughout the treatment and followed staff and writer with eyes. The site was clean, no redness, and without drainage. Staff C stated the resident often pulls at the tube and during the 3-11 shift the tube had came out. The staff member reported the resident had a Foley (urine catheter) in the area to keep it open and it wasn't bleeding. Staff C stated she had replaced the G-tube but wasn't able to hear the swish of air and there was no residual so Resident #82 was sent out to the hospital at approximately 7:30 a.m. The staff member retracted the tube came out on 3-11 shift stating it had come out on 11-7 shift. Staff G, LPN stated Staff F, DON had informed the 11-7 shift nurse per policy the facility nurses' could put a G-tube in. Staff G stated the G-tube was inserted, didn't get any residual and some liquid came from the side of it, resident was sent to hospital, and the hospital was able to verify placement. An interview was conducted with Staff F, DON on 1/23/24 at 2:45 p.m. The DON reported receiving a (telephone) call (on 1/19/24) from the night shift supervisor informing her Resident #82 was going to be sent out (to hospital) but Staff M, Interim DON, had informed the supervisor nurses could put it (G-tube) back in within 2 hours. The DON reported the resident's nurse had already called Emergency Medical Services (EMS) to transfer however it was the policy to call the DON or Regional Nurse before calling EMS, if non-emergent staff were to call the DON and talk with them to prevent a return to the hospital. Staff F stated the supervisor had informed her that Staff M had informed her nurses could put in a G-tube as long as there was no trauma and no pain. Staff F reported the supervisor had put a Foley in the area until Staff F could get to the facility and educate staff on the procedure. Staff F reported educating and completing competencies with the supervisor, Staff C, and Staff G (on the reinsertion of GTube). The DON reported she had taken the Foley out and inserted the G-tube while Staff C, Staff G, and the supervisor were at bedside watching her do it. Staff F reported receiving orders from the Nurse Practitioner (NP) to put in the G-tube and within 30 minutes the NP was in the building. The staff member stated Resident #82 was sent out for verification of placement. During an interview on 1/23/24 at 2:45 p.m., the DON (Staff F) reviewed the progress notes for Resident #82 and stated it should be documented on whether or not the G-tube was out and there should be documentation regarding the resident status, where the G-tube was found, the procedure for putting a Foley into the site, and the status of the site. An interview was conducted with the NP on 1/23/24 at 3:13 p.m. The NP reported giving the order to insert a Foley to keep the area open. During an interview on 1/23/24 at 3:56 p.m. with Staff F, DON and Staff M, Interim DON (IDON), Staff F provided the competency for Staff C, dated 1/19/24, regarding Emergency Enteral (G-tube) Tubing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105176 If continuation sheet Page 16 of 26 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 01/24/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Changes. Staff F stated the facility does not have a policy regarding the reinsertion of PEG/G-tube, they have the competency for staff. The staff members provided a copy of a physician order from the NP dated 1/19/24 for GTube Reinsertion. An interview was conducted with Staff F, DON on 1/24/24 at 9:28 a.m. The DON said the old DON had notified her recently of the policy allowing staff to reinsert a G-tube and she had not had a chance to educate the night shift or review the competency. The staff member stated the electronic record automatically puts the last documented vitals signs into the forms, but staff could press new and freehand the (new) vital signs. Staff F stated the expectation was to document the residents current vital signs for a transfer/change in condition. A review of the Emergency Enteral (G-tube) Tubing Changes competency, undated, showed the nurse would Call MD [Medical Doctor], obtain order for replacement if tube tract was greater than 6 weeks healed and only a GTube after trained and with MD order and If the tube tract was less than 6 weeks placed, insert largest size Foley or urinary catheter tubing and obtain order to send resident to hospital non-emergent. The competency did not educate staff on whether or not documentation was required pre or post procedure. 3) On 01/21/2024 at 9:00 a.m. Resident #41 was observed in bed. His Midline Intravenous (IV) site dressing on right upper arm inner aspect was dated 01/12/2024. (Photographic Evidence Provided). On 01/22/2024 at 9:30 a.m. Resident #41 was observed resting in bed, his midline intravenous (IV) dressing site was dated 01/21/2024 and was detached from the inner aspect of the right upper arm leaving the insertion site uncovered. the resident was unable to provide information regarding the IV. On 01/23/24 11:19 a.m. Resident #41 was observed resting in resident in bed, resting. The IV dressing remains loose and detached from the inner aspect of the right upper arm. During an interview on 1/23/2024 at 11:25 a.m. with the DON she confirmed the dressing was not intact, she stated the dressing should not be like that. A review of the medical record revealed Resident #41 was admitted on [DATE] with diagnoses to include hemiplegia/hemiparesis following a cerebral infarction affecting left non-dominant side, urinary tract infection and obstructive uropathy. The admission Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. Review of physician orders, dated 12/8/2023 revealed the following: 1. Admit to skilled nursing 2. Change IV dressing every seven days as well as whenever necessary (PRN) soiling and/or dislodgement on evening shift ordered 01/16/2024. 3. Document IV site appearance every shift U=unremarkable, R=redress, S=swollen, W=warm to touch, D=drainage, report any changes to physician, ordered 01/16/2024 4. Use 10 milliliter (ml) syringe with all flushes for IV every shift for flushes for seven days (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105176 If continuation sheet Page 17 of 26 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 01/24/2024 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 0684 ordered 01/12/2024. Level of Harm - Minimal harm or potential for actual harm 5. IV was inserted on 01/12/2024 Residents Affected - Some 6. Ceftazidime injection one gram IV every eight hours for seven days ordered 01/12/2024 for urinary tract infection and discontinue IV on 01/23/2024 A review of the daily skilled note evaluation, dated 01/16/2024 - 01/21/2024, for IV revealed - midline IV with dressing intact documented on all five days. A review of progress notes for 01/01/2024 - 01/24/2024 revealed documentation for midline IV dressing intact. A review of the Medication Administration Record (MAR) documentation for 01/01/2024 - 01/23/2025 revealed: 1. IV dressing changed on 01/16/2024 2. Ceftazidime one gram IV administered 01/13/2024 - 01/20/2024 every eight hours with missed dose on 01/14/2024 at 1400 (2:00 p.m.) 3. IV appearance documented 01/16/2024 night shift - 01/23/2024 day shift revealed U=unremarkable 4. IV flushes documented 01/12/2024 night shift - 01/19/2024 evening shift 5. IV inserted on 01/12/2024 at 1948 (9:48 p.m.) 6. Change IV whenever needed (PRN) dates available on [DATE]/16/2024 - 01/23/2024 revealed no documentation. A review of the policy titled Infusion Therapy Procedure, dated 08/2016, Dressing change for Vascular access Devices revealed the following: Purpose: To prevent local and systemic infection related to the IV catheter. Procedure: 5. A dressing is changed immediately if: a. The dressing is non-occlusive or soiled. b. There is drainage or moisture under the dressing. c. There are signs of irritation or inflammation at the insertion site. 9. Suggested charting/documentation a. Site assessment (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105176 If continuation sheet Page 18 of 26 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 01/24/2024 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 0684 b. preparation used Level of Harm - Minimal harm or potential for actual harm c. Type of dressing d. Catheter securement (integrity of sutures, other devices) Residents Affected - Some e. Resident response to procedure. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105176 If continuation sheet Page 19 of 26 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 01/24/2024 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** Based on observations, interviews, and record review the facility failed to provide care and services according to physician's orders related to catheter care for one resident (Resident #36) out of the two sampled residents. Findings included: On 01/21/24 at 10:10 a.m., the resident was observed in bed in his room. There was a foul urine smell in the room. Resident #36 was verbal but was not able to answer questions appropriately during an attempt to interview him. A review of the admission Record for Resident #36 showed he was admitted on [DATE] with diagnosis of personal history of urinary tract infection and neuromuscular dysfunction of bladder. Section C: Cognitive Patterns of the Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 04 out of 15 indicating severe cognitive impairment. Section H: Bladder and Bowel showed the resident had an indwelling catheter. The Order Summary Report with active orders as of 11/01/23 revealed the following: Suprapubic Catheter: Drain suprapubic catheter bag every shift as needed and record amount (07/15/23). A review of the Treatment Administration Record (TAR) for 11/01/23-11/30/23, 12/01/23-12/31/23, and 01/01/24-01/31/23 showed the amount of urine output was not recorded every shift per physician order. A review of the comprehensive care plan revealed the following: Focus: Indwelling/other catheter-Resident #36 uses a supra pubic urinary catheter with risk for infection and/or complications related to obstructive uropathy. (initiated on 12/16/22). Interventions included: observe/document/report to doctor for signs and symptoms of urinary tract infection: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. On 01/23/24 at 1:15 p.m. Staff C, Registered Nurse (RN), stated she provided catheter care and sometimes he was not compliant with care. She confirmed she was not documenting the output for urine per the physician's orders. On 1/23/24 at 1:20 p.m., the Director of Nursing (DON) stated she expects there to be documentation recorded for the urine output per the physician's orders. She stated on the order there should have been a place for nurses to document the output on the TAR. The DON confirmed there was no documentation for the output on the TAR. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105176 If continuation sheet Page 20 of 26 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 01/24/2024 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 observations, record reviews, and interviews the facility failed to ensure the medication error rate was less than 5.00%. Twenty-nine medication administration opportunities were observed and two errors were identified for one resident (#55) of four residents observed. These errors constituted a 6.9% medication error rate. Residents Affected - Few Findings included: 1) On 1/23/24 at 8:43 a.m., an observation of medication administration with Staff I, Licensed Practical Nurse (LPN), was conducted with Resident #55. The staff member dispensed the following medications: - Carvedilol 25 milligram (mg) tablet - Docusate sodium 100 mg over-the-counter (OTC) geltab - Eliquis 2.5 mg tablet - Lactulose 10 g/15mL (gram/milliliter) liquid - poured 15 mL's into medication cup - Minoxidil 10 mg tablet - Renavite OTC tablet - Sevelamer Carbonate 800 mg tablet Staff I, LPN confirmed dispensing 6 tablets and one liquid medication for Resident #55 prior to entering the resident room and administering the medications. Review of Resident #55's January 2024 physician orders and Medication Administration Record revealed the resident had the following medications to be administered at 9:00 a.m.: - Lactulose Oral Solution 10 g/15mL - Give 30 mL's by mouth two times a day every Tuesday (Tues), Thursday (Thur), Saturday (Sat), (and) Sunday (Sun) for constipation. - Sevelamer Carbonate 800 mg - Give 3 tablet(s) by mouth three times a day for binder with food. The observation revealed Staff I, LPN had administered 15 mL's of Lactulose not the 30 mL's as ordered and one tablet of Sevelamer not the three tablets as ordered. An interview was conducted on 1/24/24 at 9:35 a.m., with the Director of Nursing (DON). She stated the expectation was for staff to follow physician orders and to follow the 5 rights (of administration). She stated the five rights of medication administration are right route, right dose, right resident, right medication, and right time. A review of the policy entitled Medication Administration, General Guidelines, dated 09/18, revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105176 If continuation sheet Page 21 of 26 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 01/24/2024 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 Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Medications are administered as prescribed in accordance with manufacturers specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. The medication preparation procedure showed Prior to administration review and confirm medication orders for each individual resident on the medication administration record. Medications are administered in accordance with written orders of the prescriber. Event ID: Facility ID: 105176 If continuation sheet Page 22 of 26 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 01/24/2024 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to ensure all medications were secured appropriately limiting access to unauthorized persons 1) in one treatment cart (100 hall) of 3 treatment carts, and 2) leaving medications unsecured during medication administration. Findings included: 1) During the initial tour of the facility on 01/21/24 at 09:13 AM, observations of the 100 hall revealed a treatment cart labeled 100 hall treatment cart. Closer observations of the treatment cart revealed the lock button on the cart was fully extended exposing the red lock area. An attempt to open drawers on the treatment cart was successful revealing multiple residents topical medication stored in the lower draw. (Photographic evidence obtained). Continued observations at this time revealed there were no staff or authorized persons monitoring the treatment cart. An interview on 01/21/24 at 09:14 AM with Staff H, Licensed Practical Nurse (LPN) revealed only she and one other person had the keys to the treatment cart. She stated she locked it after she used it and it should not have been left open. An interview with Staff F, Director of Nursing (DON) on 01/24/24 at 09:44 AM revealed treatment carts should be locked at all times when not in use. 2) During an observation of medication administration with Staff H, Registered Nurse (RN) on 1/22/24 at 4:41 p.m., the medication cart was pushed to the side of the doorway of room [ROOM NUMBER] while Staff H, RN administered medications. Staff H left a bottle of Zinc tablets and 3 blister cards containing medications on top of the medication cart. On 1/22/24 at 5:21 p.m., after leaving the room, Staff H, RN confirmed the medications were left unattended on the medication cart, She stated, Yes I was in there (indicating the resident room). The Director of Nursing stated on 1/24/24 at 9:44 a.m., The minute you turn your back it needs to be locked. She confirmed the medications should have been secured. A review of the policy entitled Medication Administration General Guidelines, dated 09/18, revealed the following: During the administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications when only locked. A review of the policy entitled Medication Storage, Storage of Medication, dated 09/18, revealed the following: Medications and biologicals are stored properly, following manufacturers or provided pharmacy recommendations, to maintain their integrity and to support safe effective Drug Administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105176 If continuation sheet Page 23 of 26 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 01/24/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure hydration was provided to residents residing on the secured unit in a sanitary manner during two lunch meals (1/21/24 and 1/22/24) out of two lunch meal observed. Findings included: On 1/21/24 at 12:43 p.m. a meal cart was delivered to the 300-hall. On 1/21/24 at 12:48 p.m., Staff K, CNA, removed a tray of pre-filled uncovered cups of three different colored liquids from the second shelf of a three shelf cart and placed the tray onto the top of the meal cart. The staff member stated the cups were pre-filled on the unit. On 1/21/24 at 12:55 p.m. an observation was made of the meal cart on 300-hall moving from between rooms [ROOM NUMBERS] to outside of room [ROOM NUMBER] with the same above mentioned pre-filled uncovered cups on top. Staff were observed removing trays from the cart then placing the pre-filled cups on the tray before delivering to resident rooms. (Photographic evidence was obtained). On 1/22/24 at 12:35 p.m. an observation was made of pre-filled uncovered cups containing a pink liquid sitting on a table top in the far corner of the 300-hall dining room. Staff L, Certified Nursing Assistant (CNA) removed the tray of pre-filled cups from the dining room and placed it on the bottom shelf of a 3-shelf rolling cart then moved the cart to the area between rooms [ROOM NUMBERS]. The second shelf of the cart held pre-filled cups of a light tan liquid. The observation showed staff's shoes were approximately 4 inches from the cups on the bottom shelf and multiple staff were removing the cups, placing them on the meal trays, then delivering to the residents in their rooms. An interview was conducted on 1/24/24 at 10:05 a.m., with the Registered Dietitian (RD). The RD stated drinks were covered when coming from kitchen, and stated she did not know what the facility policy was on the subject. An interview was conducted on 1/24/24 at 10:30 a.m. with the Certified Dietary Manager (CDM). The CDM stated empty cups were on trays from the kitchen and containers of juice, tea, and coffee were sent to the units. She stated the CNA's are allowed to serve 2 doorways from the cart without the cups being covered. A review of photographic evidence was conducted with the CDM and she stated it was not appropriate to have the pre-filled drinks on the tray and staff should not be pre-pouring drinks in that manner. She reviewed the photo of the tray of drinks on the top of the meal cart and stated, Oh no they shouldn't be doing that. A review of the policy entitled Dining Service, effective January 2021, revealed the following: Purpose: To provide Residents a pleasurable dining experience by offering nutritious, attractive meals served in a courteous and dignified manner. Procedure: The following items were placed on each room tray: other beverage cup (if requested), milk glass, condiments, and food items according to menu. The room service procedure revealed all (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105176 If continuation sheet Page 24 of 26 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 01/24/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm glassware on tray was to be inverted as space allowed and to provide pitchers of liquid on a separate cart for staff to pour, and to cover and/or wrap all items on tray with a lid or plastic wrap prior to the tray leaving the kitchen to protect food and fluids from contamination during transportation. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105176 If continuation sheet Page 25 of 26 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 01/24/2024 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 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Based on record review and interviews the facility failed to update the facility-wide assessment to determine what staff competencies are needed for care of residents with different types of acuities. Findings included: Observations made during the survey between 1/20/2024 to 1/24/2024 revealed the facility had residents with indwelling catheters, tracheotomies, intravenous lines, and wounds. These acuities are listed on the Facility Assessments. Review of the Facility Assessment (FA), dated 10/3/2023, showed the resident population, emergency plans, facility description, and type of conditions and acuity the facility cares for. The section titled Disease/Conditions; Physical Disabilities; Cognitive disabilities; Psychiatric Diagnosis; and Acuity. Several columns are at the top of the sections indicating if the resident is admitted - yes, no; if special equipment needs - yes, no, N/A (not applicable); equipment needed; Competency Required - Yes, No, N/A. The Physical Disabilities section is the only section completed for equipment needed and marked yes for staff competency. All other sections were observed to be blank. An interview was conducted on 01/24/2024 at 10:25 AM, with the Nursing Home Administrator (NHA), Staff M, Interim Director of Nursing (IDON), and the facility Consultant for Risk Management (CRM). The NHA and Staff M, IDON confirmed they do not have policy and procedures for many of the nursing services provided in the facility. The facility utilizes the [Nursing Care Manual name] and staff competencies. In review of the FA under the section Acuity which has a listing of nursing services provided, the NHA and Staff M, IDON confirmed nothing is marked on the FA regarding what items are needed and when to have staff competencies completed. The NHA confirmed this section needs to be completed and kept up to date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105176 If continuation sheet Page 26 of 26