Health inspection·May 19, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the SBAR (Situation, Background, Assessment, Recommendation) Communication Form and Progress Note for RNs/LPN/LVNs (Registered Nurse/Licensed Practical Nurse/Licensed Vocational Nurse) dated 5/04/23 read, Resident found on floor . sitting on floor mats on her knees. Documentation indicated the resident's Primary Care Provider (PCP) was notified of the fall on 5/04/23 at 7:30 AM and read, Sent to hospital for additional Eval (evaluation). Documentation indicated the resident's family/Health Care Agent was notified of this 5/04/23 fall on 5/11/23 at 2 PM, 6 days after the incident. The incident log revealed resident #1 was observed sitting on the floor in the hallway on 5/04/23 at 9 PM. This indicated the resident sustained a fall earlier that day that was not entered on the incident log. On 5/10/23, the form read, Pain in R (right) hip . confused, and indicated the PCP was notified on 5/10/23 at 9 AM, and the resident's family/Health Care Agent was notified on 5/11/23 at 2 PM, 1 day after the incident. However, review of the incident log and discussion with the Director of Nursing (DON) revealed falls on 5/10/23 were at 3:47 PM and 4:04 PM. On 5/17/23 at 2:59 PM, the incident log, the SBAR communication forms, and the process for notification of family were discussed with the DON. She stated there was miscommunication between the resident's nurse and the East Wing Unit Manager (UM), verbalizing they thought each of them had contacted the resident's granddaughter. On 5/17/23 at 3:17 PM, the Assistant DON/East Wing UM confirmed the resident's granddaughter was the contact person for any change in the resident's condition. The incident log was reviewed with the ADON/UM, and she confirmed the resident had two separates falls on 5/10/23. When asked about notification to the responsible party, the ADON/UM stated an Agency nurse worked on the East Wing on 5/10/23, and the nurse assumed the ADON/UM notified the responsible party about the resident's falls, and she assumed the Agency nurse had called the family. She confirmed the resident's family/responsible party was not made aware of the two falls that occurred on 5/10/23 until 5/11/23. On 5/17/23 at 4:32 PM, the Social Service Director (SSD) stated resident #1's granddaughter came to the facility on 5/11/23 for a care plan meeting and informed the granddaughter her grandmother was not acting the same. The SSD recalled she observed the resident and told the granddaughter, You know she had a fall. The granddaughter said she knew nothing about the fall. The SSD indicated she notified the ADON/East Wing UM. The SSD noted the resident's falls were discussed at the care plan meeting and the granddaughter requested her grandmother be sent to the hospital to be assessed. The SSD confirmed resident #1's granddaughter was not made aware of the resident's falls that occurred on 5/10/23, until 5/11/23. The facility's policy Notification of Changes, implemented 11/2020, read, The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105332 If continuation sheet Page 2 of 11 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 105332 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winter Park Care and Rehabilitation 2970 Scarlett Rd Winter Park, FL 32792 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report falls resulting in major injuries and transfer to the hospital to the relevant regulatory agencies for 2 of 3 residents reviewed for falls with major injuries, of a total sample of 10 residents (#1 & #2). Findings: 1. Resident #1, an [AGE] year-old female, was admitted to the facility on [DATE], and readmitted on [DATE]. Her diagnoses included metabolic encephalopathy, dementia, diabetes type II, anxiety disorder, and mood (affective) disorder. On 4/29/23, the diagnosis non-displaced fracture of base of neck of right femur was added. The resident's admission Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 4/12/23 revealed the resident's cognition was severely impaired, with a Brief Interview for Mental Status (BIMS) score of 03 out of 15. The assessment noted resident #1 required extensive assistance of two staff persons for bed mobility, transfers, dressing, and personal hygiene. Her balance during walking, transfers, moving from seated to standing position was not steady and the resident was only able to stabilize with staff assistance. Review of the facility's incident log from March 2023 to current revealed that on 4/23/23 at 1:38 PM, resident #1 had a fall. Discussion with the Director of Nursing revealed the resident was observed getting out of her wheelchair and putting herself on her buttock in the East Wing hallway. Review of the eInteract change in condition form dated 4/24/23 read, Patient had a fall on 4/23. Patient continues to have pain to R (right) leg. X-ray to R hip and R leg ordered. X-ray done today on 4/24. Results show fx (fracture) to R hip and R femur. The document indicated the physician was notified of the X-ray results, and the resident was transferred to the hospital for evaluation and treatment. The hospital's history and physical, dated 4/25/23, revealed her chief complaint was fall. The document read, Presented to the ER (Emergency Room) s/p (status/post) fall. History is fairly limited due to patient's advanced dementia . According to the ER physician, apparently she had an unwitnessed fall on Sunday and evaluation by imaging revealed acute nondisplaced subcapital right femoral neck fracture. The document noted the resident had limited range of motion to her right lower extremity, and was oriented to herself, but not oriented to place, and time. Computed Tomography (CT) scan of the abdomen and pelvis, X-rays of the left hip, right hip, and femur, completed at the hospital, indicated the resident had an acute right femur subcapital neck fracture with mild impaction and external rotation. The plan included inpatient admission, and nothing by mouth for surgery. The surgical procedure Open Reduction Internal Fixation (ORIF) of the resident's right femoral neck fracture was done on 4/26/23. Open reduction internal fixation (ORIF) is a surgery to fix severely broken bones. It's only used for serious fractures that cannot be treated with a cast or splint. (Retrieved on 5/24/23 from healthline.com). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105332 If continuation sheet Page 3 of 11 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 105332 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winter Park Care and Rehabilitation 2970 Scarlett Rd Winter Park, FL 32792 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (3008), dated 4/28/23, revealed resident #1's primary diagnosis was closed fracture of neck of right femur and indicated the resident was alert, disoriented, but can follow simple instructions. A nurse's progress note dated 4/23/23 at 9:40 PM revealed the resident was observed getting up from her wheelchair while sitting in the East Wing hallway and placing herself on the floor on her buttocks. A progress note on 4/24/23 at 8 PM read, Abnormal X-ray report called in . reports a R (right) hip fx (fracture) and R femur fx. Documentation indicated the provider was notified, and orders were obtained to send the resident to the ER via emergency transport. On 5/17/23 at 1:06 PM, resident #1 sat in her wheelchair in the main dining room. Her head was bowed, her eyes closed, and she did not respond when spoken to. The resident's granddaughter was visiting, and stated she visited the resident at the facility every other day. The granddaughter recalled that on 4/24/23, she received a call from the facility, and was told the resident fell. She said she did not know how the fall occurred, assumed it was from her bed, and was told her grandmother was okay. The granddaughter stated she received a call the next morning from a nurse who told her an Xray was done, showed the resident had a broken hip, and resident #1 was sent to the ER. On 5/18/23 at 5:02 PM, the resident's fall with fracture was discussed with the Director of Nursing (DON), Administrator, and the Regional Director of Operations. They confirmed the resident had a fall on 4/23/23, and X-rays done on 4/24/23 revealed the resident sustained a fracture of her right femur and was transferred to the hospital for evaluation and treatment. The DON stated the facility did not do an Immediate or 5-day AHCA report for the incident. The Regional Director of Operations stated the resident's fall was discussed and did not meet criteria for a reportable or adverse incident, because the facility followed the resident's care plan that was in place, and the fall was witnessed. The Regional Director of Operations, and the DON stated the facility's assumption was that the fracture was caused from the resident sitting on the floor, the resident has bone mineralization, and the fracture was not considered an injury of unknown origin. They stated the fall with subsequent fracture was not within the control of the facility, and stated a nurse was with the resident at the time of the fall and had direct eye contact on her. The resident's baseline care plan for falls dated 4/07/23 was reviewed with the DON. The interventions noted were, Complete Fall Risk Screen on admission, quarterly and PRN (as needed), place call bell within easy reach, and cue for safety awareness. The DON acknowledged no other interventions were included on the baseline care plan. On 5/19/23 at 10:49 AM, the DON stated the facility determined the resident's fracture was sustained from her fall on 4/23/23. She said the resident was sent out to the hospital on 4/24/23, after complaining of pain during her interaction with therapy. The Regional Nurse Consultant stated she was involved in the team discussion/decision regarding the resident's fall with fracture, and in review, it was decided the incident did not meet the criteria for an adverse/reportable incident. She stated the fall was witnessed, the facility was following the resident's care plan of redirecting her from another resident's room, and they could not anticipate the resident would suddenly stand up and plop herself down on the floor. 2. Resident #2, an 84 -year-old male, was admitted to the facility on [DATE]. His diagnoses (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105332 If continuation sheet Page 4 of 11 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 105332 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winter Park Care and Rehabilitation 2970 Scarlett Rd Winter Park, FL 32792 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few included diffuse traumatic brain injury, fracture nasal bones, chronic obstructive pulmonary disease, generalized muscle weakness, difficulty walking, and repeated falls. The resident's Medicare 5-day Minimum Data Set (MDS) assessment with ARD of 4/03/23 revealed the resident's cognition was severely impaired with a BIMS score of 06/15. The assessment noted resident #2 required extensive assistance of two staff persons for bed mobility, transfers, dressing, toilet use, and personal hygiene. His balance during transitions and walking, moving from seated to standing position, and surface- to-surface transfer was not steady and the resident was only able to stabilize with staff assistance. The Emergency Department Physician Note dated 4/10/23 read, Patient . fell when trying to get up . Hit his face, nose with the floor . Head and facial trauma . His diagnosis was Closed fracture of nasal bone, blunt head trauma. CT scan of the facial bones revealed Acute nondisplaced fractures involving the bilateral nasal bones. On 5/18/23 6:19 PM, the DON stated she spoke with the Regional Nurse Consultant and was advised the facility was following the resident's care plan, so they did not have to do an adverse/reportable incident for the fall causing fracture of the resident's nose. She stated the fall was unwitnessed, the facility did not know how it happened, and the resident could not tell what happened. She stated an investigation was done, but she was not sure what the root cause was. She confirmed the resident had an unwitnessed fall, sustained a fracture, and was sent out to a higher level of care, but the team decided the incident did not meet criteria for an adverse incident. On 5/19/23 at 11:05 AM, the Regional Nurse Consultant stated the incident was discussed, and resident #2's fall with fracture did not meet criteria for an adverse/reportable incident. She stated the facility was following the resident's care plan. The facility did not have a policy for Adverse/Reportable incidents. The DON and Regional Nurse Consultant stated the facility followed the State's regulations. The Florida Statutes 429.23 Internal risk management and quality assurance program; adverse incidents and reporting requirements read, Adverse incident means An event over which facility personnel could exercise control rather than as a result of the resident's condition and results in . Fracture or dislocation of bones or joints . Any condition that requires the transfer of the resident from the facility to a unit providing more acute care due to the incident rather than the resident's condition before the incident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105332 If continuation sheet Page 5 of 11 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 105332 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winter Park Care and Rehabilitation 2970 Scarlett Rd Winter Park, FL 32792 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to thoroughly investigate falls resulting in major injuries for 2 of 4 residents reviewed for falls of a total sample of 10 residents (#1 & #2). Residents Affected - Few Findings: 1. Resident #1, an [AGE] year-old female, was admitted to the facility on [DATE], and readmitted on [DATE]. Her diagnoses included metabolic encephalopathy, dementia, diabetes type II, anxiety disorder, and mood (affective) disorder. On 4/29/23, the diagnosis non-displaced fracture of base of neck of right femur was added. The resident's admission Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 4/12/23 revealed the resident's cognition was severely impaired, with a Brief Interview for Mental Status (BIMS) score of 03/15. The assessment noted resident #1 required extensive assistance of two staff persons for bed mobility, transfer, dressing, and personal hygiene. Her balance during transitions and walking for moving from seated to standing position, and surface-to-surface transfer- was not steady, and the resident was only able to stabilize with staff assistance. Progress Note written on 4/23/23 at 9:40 PM revealed the resident was observed getting up from her wheelchair while sitting in the East Wing hallway and placing herself on the floor on her buttocks. Progress Note on 4/24/23 at 8 PM read, Abnormal x-ray report called in . reports a R (right) hip fx (fracture) and R femur fx. Documentation indicated the provider was notified, and orders were obtained to send the resident to the ER via emergency transport. On 5/18/23 at 5:02 PM, the resident's fall with fracture was discussed with the DON, Administrator, and the Regional Director of Operations. They confirmed that the resident had a fall on 4/23/23, and X-rays done on 4/24/23 revealed the resident sustained a fracture of her right femur and was transferred to the hospital for evaluation and treatment. On 5/18/23 at 5:02 PM, the DON stated that on 4/23/23 information obtained via telephone from the resident's Primary Nurse, Licensed Practical Nurse (LPN) B, who was an Agency nurse, revealed she was watching the resident but had to give medications, and Registered Nurse (RN) A said she would watch the resident. LPN B reported RN A observed the resident getting up from her wheelchair in another resident's room. She explained RN A was trying to get the resident out of the room, and the resident was getting upset and did not want to sit in her wheelchair, so she placed herself on the floor. The DON stated the resident was assisted from the floor to her chair and back to bed by the two nurses. She stated that to her understanding, Certified Nursing Assistants (CNAs) were providing care. However, she verbalized that statements were not obtained from any of the CNAs on duty at that time, and investigation was not done to ascertain when care was last provided for resident #1. She was unable to provide a root cause for the fall, and the Regional Nurse Consultant (RNC) and DON stated the assumption was that the resident's right hip fracture was caused from her sitting on the floor. However, record review revealed X-rays were not done until the following day, 5/11/23. This was confirmed by the DON. 2. Resident #2, an 84 -year-old male was admitted to the facility on [DATE]. His diagnoses included diffuse traumatic brain injury, fracture nasal bones, chronic obstructive pulmonary disease, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105332 If continuation sheet Page 6 of 11 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 105332 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winter Park Care and Rehabilitation 2970 Scarlett Rd Winter Park, FL 32792 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 0610 generalized muscle weakness, difficulty walking, and repeated falls. Level of Harm - Minimal harm or potential for actual harm The resident's Medicare 5-day Minimum Data Set (MDS) assessment with ARD of 4/03/23 revealed the resident's cognition was severely impaired with a BIMS score of 06/15. The assessment noted resident #2 required extensive assistance of two staff persons for bed mobility, transfer, dressing, toilet use, and personal hygiene. His balance during transitions and walking for, moving from seated to standing position, and surface- to-surface transfer was not steady and the resident was only able to stabilize with staff assistance. Residents Affected - Few The Emergency Department Physician Note, dated 4/10/23, read, Patient . fell when trying to get up . Hit his face, nose with the floor . Head and facial trauma. His diagnosis was Closed fracture of nasal bone, blunt head trauma. Computed Tomography (CT) scan of the facial bones revealed Acute nondisplaced fractures involving the bilateral nasal bones. On 5/18/23 at 6:19 PM, the DON stated resident #2 has unsteady gait, was confused, had impaired judgement, and poor safety awareness. She stated the resident was trying to get up and walk around his room. He also uses oxygen which would put him at a higher risk for falls, and she was told he was in his room close to his chest of drawers. She said probably that was when he fractured his nose. She stated she obtained a written statement from the resident's direct care nurse, Registered Nurse (RN) C, who reported he was notified by Staffing Coordinator/CNA D that the resident was on the floor. On 5/18/23 at 6:38 PM, RN C stated resident #2 was very confused, had dementia, sometimes was agitated. He stated the resident tried to do things by himself and would try to get out of his chair three to four times in an hour. RN C confirmed resident #2 was in his assignment on 4/10/23, and recalled he was passing medication when CNA D notified him that the resident was on the floor. RN C stated he went to the resident's room and assessed him. The resident had an open area on the bridge of his nose, and his nose was bleeding. He verbalized he called the physician and obtained order to send the resident to the Emergency Room. He was unable to say what the resident was doing prior to his fall. On 5/19/23 at 10:05 AM, in a telephone interview, Staffing Coordinator/CNA D recalled that on 4/10/23, she was in her office, when she heard a CNA scream. The Staffing Coordinator/CNA could not recall who the CNA was, but recalled she informed RN C. She said usually in those situations, she would sometimes assist, or would sit at the nurses' station to direct Emergency Medical Services when they came in, but she could not recall what she did that day; she stated she never saw the resident on the floor. On 5/19/23 at 11:09 AM, the incident was again discussed with the DON. She stated she interviewed RN C regarding the incident, but did not interview the resident's assigned CNA, or any other staff on duty at the time, and verbalized the resident could not voice what happened. The DON confirmed that a thorough investigation of the incident was not done. The facility's policy Fall Prevention Program implemented on 11/01/20, and reviewed/revised on 10/18/22 read, When any resident experiences a fall, the facility will . complete a fall investigation which may include obtaining statements from the resident and/or witnesses. Review of the facility's policy Abuse, Neglect and Exploitation, with copyright date of 2021, revealed that investigation included, Identifying and interviewing all involved persons, including .witnesses, and others who might have knowledge of the allegations . Providing complete and through (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105332 If continuation sheet Page 7 of 11 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 105332 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winter Park Care and Rehabilitation 2970 Scarlett Rd Winter Park, FL 32792 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 0610 documentation of the investigation. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105332 If continuation sheet Page 8 of 11 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 105332 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winter Park Care and Rehabilitation 2970 Scarlett Rd Winter Park, FL 32792 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide adequate supervision to prevent fall with major injury, and subsequent falls for 1 of 4 residents reviewed for accidents, of a total sample of 10 residents (#1). Findings: Resident #1, an [AGE] year-old female, was admitted to the facility on [DATE], and readmitted on [DATE]. Her diagnoses included metabolic encephalopathy, dementia, diabetes type II, anxiety disorder, and mood (affective) disorder. On 4/29/23, the diagnosis nondisplaced fracture of base of neck of right femur was added. The resident's admission Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 4/12/23 revealed the resident's cognition was severely impaired, with a Brief Interview for Mental Status (BIMS) score of 03/15. The assessment noted resident #1 required extensive assistance of two staff persons for bed mobility, transfer, dressing, and personal hygiene. Her balance during transitions and walking for moving from seated to standing position, and surface-to-surface transfer was not steady, and the resident was only able to stabilize with staff assistance. Review of the resident's Morse Fall Risk evaluation dated 4/06/23 indicated the resident was at risk for falls, with a score of 13.0. On 4/23/23, and 5/10/23, her fall risk score was 75.0, indicating the resident was at high risk for falling. The document read, Morse Fall scoring: High Risk 45 and higher, Moderate risk 25-44, low risk 0-24. Review of the facility's incident log for the period March 2023 to current revealed resident #1 had the following falls. On 4/23/23 at 1:38 PM, resident #1 was observed getting out of her wheelchair and putting herself on her buttock in the hallway of the East Wing. On 5/04/23 at 9:00 PM, the resident was observed sitting on the floor in the hallway on the East Wing. On 5/10/23 at 3:47 PM, resident #1 was found on the floor in her room next to her bed on the floor mat. On 5/10/23 at 4:04 PM, the resident fell forward on to the floor in her room, from her wheelchair. The resident's SBAR Communication Form dated 5/04/23 revealed the resident was found on the floor, and the document indicated the primary care clinician was notified on 5/04/23 at 7:30 AM. However, the incident log showed that at 9 PM, the resident was observed sitting on the floor, indicating a second fall occurred on 5/04/23. An incident note with effective date 5/10/23 at 7:30 AM revealed the resident was found sitting on the floor at the foot of her bed. The resident had three falls on 5/10/23, at 3:47 PM, 4:04 PM, and the fall at 7:30 AM, which was not listed on the facility's incident log. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105332 If continuation sheet Page 9 of 11 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 105332 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winter Park Care and Rehabilitation 2970 Scarlett Rd Winter Park, FL 32792 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 5/17/23 2:41 PM, the resident's falls were discussed with the Director of Nursing (DON). She stated she was informed by staff that resident #1 tends to get up from her wheelchair if her brief is wet and stated that on 4/23/23, status post the resident's fall, range of motion (ROM) was done, and the resident had no complaint of pain. Care plan interventions in place, were to anticipate needs, and provide prompt assistance. The DON stated that on 4/24/23, the resident complained of pain in her right hip, an X-ray was done, and revealed the resident sustained a right hip fracture, and she was sent out to the hospital where surgery was performed on her right hip. The resident returned to the facility on 4/29/23. On 5/04/23, the resident got up from her wheelchair and fell, ROM was done, and the resident was unable to bend her right leg, and orders were obtained to send the resident to the ER. Resident #1 returned to the facility on 5/05/23 and sustained additional falls on 5/10/23. An explanation for the discrepancy between the incident log and documentation on other documents could not be given. On 5/17/23 at 1:06 PM, resident #1 sat in her wheelchair in the main dining room. Her head was bowed, her eyes closed, and she did not respond when spoken to. The resident's granddaughter was visiting, and stated she visited the resident at the facility every other day. The granddaughter recalled that on 4/24/23, she received a call from the facility, and was told the resident fell. She verbalized she did not know how the fall occurred and assumed it was from her bed. She was told that the resident was OK. The granddaughter stated she received a call the next morning from a nurse who told her an X-ray was done, and showed the resident had a broken hip, and she was sent to the ER. The resident's granddaughter recalled that a week ago on 5/11/23, she came into the facility for a care plan meeting and noted the resident was lethargic. She asked the staff what happened to the resident and was told she had two falls in two days. The granddaughter stated the facility did not call her, she had no missed call on her phone, and no messages from the facility. She stated she did not get any explanation about the falls, and got upset, and wanted to know why she was not called. The granddaughter recalled she told the facility, that they should have sent the resident to the emergency room (ER) immediately and requested that the resident be sent out to the ER that day. She stated that since the resident sustained the fall with fracture, she was not responding as she used to. She explained that normally the resident was talkative, but all that changed since she fractured her hip. The granddaughter stated she had been at the facility for about an hour, and the resident had not opened her eyes, talked to her, or lifted her head. On 5/18/23 at 11:52 AM, CNA E stated resident #1 could not express her needs. She said the resident tries to get up out of her wheelchair if her brief was wet or soiled. CNA E said that prior to the resident's fracture, safety was a team effort, as the resident continuously tried to get out of her wheelchair all day. She stated the Unit Manager (UM) was aware, and all CNAs, and nurses were to keep eyes on her. On 5/18/23 at 1:33 PM, the Occupational Therapist (OT) stated that on admission, resident #1 had poor safety awareness. Therapy was working with transfer, safety, ambulation, ADLs, resident was able to ambulate holding on to side rails, and verbalized the resident's gait was not steady. The OT stated that on 4/24/23 when she saw the resident, she noticed the resident groaned and rub her right thigh. Immediately she notified the nurse and asked if she had a fall recently, and asked if X-rays were done She was told no, because the resident was not complaining, and there was no change in her condition. The resident was transferred to the hospital, and surgery was performed. The OT stated that currently, the resident required more help with ambulation, and still had poor safety awareness, diagnosis of dementia, and had poor carry over of safety techniques taught to her. On 5/18/23 at 5:02 PM, the DON stated interventions on the resident's Baseline Care Plan dated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105332 If continuation sheet Page 10 of 11 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 105332 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winter Park Care and Rehabilitation 2970 Scarlett Rd Winter Park, FL 32792 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 0689 Level of Harm - Minimal harm or potential for actual harm 4/07/23 for at risk for falls and fall related injuries were: complete fall risk screen, place call bell within easy reach, and cue for safety awareness. She confirmed that the Morse Fall Scale for the resident completed on 4/06/23 indicated the resident was at risk for falls, and the only interventions implemented for the resident were the three listed on the Baseline care plan. When asked what level of supervision was required for the resident, the Regional Director of Operations stated, That question was not answered specifically. Residents Affected - Few Review of the resident's baseline care plan dated 4/29/23, status post her right hip fracture, revealed the same three interventions listed on the baseline care plan dated 4/07/23. No additional interventions were documented to help to mitigate the resident's risk for falls and/or fall, related injuries. This was confirmed by the DON. On 5/19/23 at 10:25 AM, in a telephone interview, RN A stated resident #1 attempted to get up all the time from her wheelchair and walk. She stated her gait was not steady, and staff had to keep her close to their medication cart to keep an eye on her. On 5/19/23 at 12:04 PM, the East Wing RN/Unit Manger stated that on admission the resident was assessed at high risk for falls. She verbalized the resident would try to stand repeatedly if she was incontinent, and instead of keeping her in her room, the resident would be placed in view of both hallways. However, this intervention was not initiated/implemented on the resident's care plan. On 5/19/23 at 1:15 PM, CNA F stated that prior to the resident's fall on 4/23/23, resident #1 was confused, and tried to get up out of her wheelchair frequently. She said the nurses would watch the resident, and when the nurses went on break, the CNAs would watch her. There was no specific assignment regarding supervision for the resident. On 5/19/23 at 3:21 PM, the DON stated the resident received supervision, stating that when a resident had a fall, it was the standard to complete neurological checks, where the resident would be observed and assessed on a regular basis. She stated the resident was placed on elopement risk on 4/29/23, and a care plan was implemented on 5/04/23 that addressed supervision. The resident's care plan for at risk for falls and fall related injury related to impaired mobility dated 4/24/23 was reviewed with the DON. An intervention initiated on 5/10/23 was every 15-minute checks. This was after three falls on 5/10/23, no interventions to address supervision were identified on the risk for fall care plan. The resident's care plan for at risk for elopement/exit seeking initiated on 5/04/23 read, provide direct staff supervision for resident when attending an out-of-facility activity interventions did not address falls, this was confirmed by the DON. Review of the facility's policy Fall Prevention Program, implemented on 11/1/2020 and reviewed/revised on 10/18/22, revealed that each resident would be assessed for fall risk and would Receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. The document indicated that protocols for Low/moderate Risk included implementation of patient centered interventions that would decrease the risk of the resident falling, and included routine rounding, and high-risk protocols included increased frequency of rounds. The resident's care plan for falls and fall related injury did not address protocols regarding rounding/supervision. Review of the Facility Assessment, reviewed on 3/27/2023, read, Services and care offered based on resident's needs included, Mobility and fall prevention. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105332 If continuation sheet Page 11 of 11