Health inspection·November 15, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few investigation. The ADON stated the incident was being investigated as an injury of unknown origin and the facility was gathering documents and obtaining statements from nurses and Certified Nursing Assistants who worked 11/11/23 to 11/12/23 on the 11 PM to 7 AM shifts, and on the 7 AM to 3 PM shifts. The ADON was unable to say when the Department for Children and Family (DCF) was notified, or if the Immediate Federal Report regarding the injury of unknown origin was submitted to the Agency For Health Care Administration (AHCA). On 11/15/23 at 12:51 PM, the Administrator stated he was made aware of redness to the residents' right eye and forehead on 11/12/23 around 8 AM. He explained that DCF visited the facility on 11/14/23 between 1:00 PM, and 1:30 PM, and informed the facility that someone had called and reported an allegation of abuse regarding resident #1. He stated he obtained statements from staff on 11/12/23, because there was an incident, and the resident had some swelling, redness, and shoulder pain. He said the investigation was opened on 11/12/23 as an injury of unknown origin, and the Agency For Health Care Administration (AHCA) immediate Federal report was submitted on 11/14/23 at 3:00 PM. This was approximately 55 hours after the facility was made aware, and an initial investigation regarding injury of unknown origin was initiated. The facility's policy Abuse, Neglect and Exploitation implemented on 11/03/20, and revised 7/2023, read, Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies .within specified timeframes: a. Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105332 If continuation sheet Page 2 of 9 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 11/15/2023 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 a potential fall for 1 dependent resident of a total sample of 5 residents, (#19). Residents Affected - Few Findings: Resident #19, a [AGE] year-old male was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included diabetes type II, pain in leg, left artificial hip joint, left knee contracture, bipolar disorder, dementia, and on 11/01/23 displaced fracture of lower epiphysis (separation) of left femur was added. Review of the facility's Incident Log showed entry for resident #19 of an unwitnessed fall on 10/26/23 at 10:55PM. Review of the resident's hospital's history and physical dated 10/27/23 revealed the resident presented to the Emergency Department for a ground-level fall, and read, Patient found to have a left leg deformity. Unknown mechanism of fall because of dementia .Ortho following plans for OR (operating room) for fixation today. Documentation revealed the resident's principal problem was a, closed displaced fracture of distal epiphysis of left femur. The resident's annual Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 11/02/23 revealed the resident had impairment in functional limitation in range of motion to one side of his upper and lower extremities and had one fall with major injury. On 11/13/23 at 2:29 PM, Licensed Practical Nurse (LPN) /Interim Unit Manager (UM) for the East Wing recalled she heard that resident #19 had a fall. She explained she was not at the facility when the incident happened, but the incident report revealed the resident had a fall during the 11PM-7AM shift on 10/25/23. On 11/13/23 at 4:30 PM, Licensed Practical Nurse (LPN) B recalled she was at work on 10/26/23 when resident #19 was sent out to the hospital. She verbalized she was not the resident's primary nurse, but was one of the nurses, along with the Evening Supervisor, and Registered Nurse (RN) C who went in to assess the resident. LPN B stated RN C spoke Spanish, the resident's primary language, and the resident told RN C that he was on the floor, and two persons put him back to the bed. LPN B recalled the supervisor interviewed Certified Nursing Assistant (CNA) D that worked on the 11PM-7AM shift 10/24/23-10/25/23, and CNA D confirmed with the Supervisor that the resident was on the floor, and she and RN E placed him back in bed. LPN B said there were no notes documented regarding the fall and stated the Assistant Director of Nursing (ADON), and the Administrator did not interview her, or obtain a statement from her. On 11/14/23 at 9:49 AM, the incident was discussed with the Administrator, and the ADON. The Administrator stated the facility started an investigation on 10/27/23 at 3PM, he recalled CNA D reported that resident #19 may have had a fall, and she notified RN E. However, RN E reported that the resident did not have a fall. The Administrator and ADON shared that they reviewed the resident's clinical records, and interview with the resident's CNA of 10/26/23 revealed that at around 10:30 PM CNA F went to provide care for the resident, he started making indications of pain, and the physician, and the resident's guardian were contacted. Physician' s order was to send the resident to the hospital. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105332 If continuation sheet Page 3 of 9 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 11/15/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The Administrator stated the investigation was started after the facility received a report from the hospital that the resident had a fracture. He stated statements were obtained from staff, including RN E, CNA F, CNA D, and RN C. He confirmed that a statement was not obtained from LPN B, and that he interviewed the resident's roommate, but did not document the interview. On 11/15/23 at 8:06 AM, in a telephone interview, CNA D stated she worked on the 11PM-7AM shift and confirmed that resident #19 was a part of her assignment. The CNA stated the last time she worked with the resident, she could not recall the date, at approximately 5 AM she went into the resident's room, and found the resident on the floor. The CNA stated she reported her observation to the resident's nurse RN E, and the RN told her to assist her to get the resident back in bed. CNA D stated they assisted the resident back to bed, and she provided care for the resident, and left for the day. The CNA stated she wrote a statement for the ADON, and Administrator, and documented her observation. Review of documented statement obtained from RN C dated 10/26/23 read, Resident state he fell last night from bed. CNA D's statement dated 10/26/23 read, (Resident #19's name) fall reported to (RN E's name) @5am. Record review showed discrepancy between the incident log, statements obtained from staff, and review of the resident's clinical records as to the cause of the resident's left femur fracture. The Administrator said the facility could not determine 100% that there was a fall, and the root cause analysis showed the fracture was caused from stretching, and application of a left leg brace which was being applied since 4/12/22. He stated the facility ended up calling it an injury of unknown origin, and said, there was an injury, there was a fracture. The facility's policy Abuse, Neglect and Exploitation implemented on 11/03/20, and revised 7/2023, read, Possible indicators of abuse include, but are not limited to : physical injury of a resident, of unknown source .An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occurs. Written procedures for investigations include: Identifying and interviewing all involved persons, including the alleged victim .witnesses, and others who might have knowledge of the allegations; Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and Providing complete and through documentation of the investigation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105332 If continuation sheet Page 4 of 9 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 11/15/2023 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 0635 Provide doctor's orders for the resident's immediate care at the time the resident was admitted. 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 ensure the hospital discharge instructions for a surgical wound, and a wound management system were transcribed to the resident's electronic medical record, to ensure appropriate monitoring by nurses for 1 resident, of a total sample of 5 residents, (#19). Residents Affected - Few Findings: Resident #19, a [AGE] year-old male was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included diabetes type II, pain in leg, left artificial hip joint, left knee contracture, bipolar disorder, dementia, and on 11/01/23 displaced fracture of lower epiphysis (separation) of left femur was added. Review of the hospital Discharge summary dated [DATE], revealed the resident's admission and discharged diagnosis was a closed displaced fracture of the distal epiphysis of the left femur. Documentation read, brought by EMS (Emergency Medical Services) . d/t (due to) left leg deformity after a fall. He was found to have left Vancouver C distal femur fracture and orthopedic surgery (Dr's name) took pt (patient) for fixation left femur 10/28. PREVENA incisional management system to surgical incision Wound Care: PREVENA 7-DAY or PREVENA 14 -day incisional management system Charge machine daily Dressing should last 14 days .Once therapy is complete, remove PREVENA dressing and begin daily dry dressing changes with gauze and tape until first post-operative appointment. 'Prevena . is a wound management system that is placed over a closed surgical incision. The device applies continuous negative pressure. This helps promote healing .The device is single use and can stay in place for up to 7 days. (Retrieved from NICE (National Institute for Health and Care Excellence). org.uk 11/20/2023.) Review of the resident's physician orders showed no order in place to address the wound management system, or for monitoring of the surgical site. A progress note dated 11/02/23 at 3:40 PM, documented by the wound care nurse read, Call placed to orthopedic Dr. (name) inquired about orders for wound vac. This nurse was informed, to leave wound vac in place until the battery no longer functions, at that time replace dressing with dry dressing daily, and prn (as needed). On 11/13/23 at 2:29 PM, Licensed Practical Nurse (LPN) /Interim Unit Manager (UM) for the East Wing stated resident #19 did not have a wound vac in place. Review of the resident' active and discontinued physician orders, conducted with LPN/Interim UM did not identify an order for the wound management system, or for monitoring of the resident's surgical site. Observation of resident #19 conducted with LPN/Interim UM showed a wound management system to the resident's surgical site to his left femur. The LPN/Interim UM verbalized she had wound care experience, and stated the battery for the system was dead. She said an order should be in place for the system, the machine should be checked every shift to ensure it was working properly, and if not, the company needed to be informed. The LPN/ interim UM explained that the wound management system was placed by the surgeon status post, surgery, and would remain in place between 7- 14 days depending on the physician orders. The LPN/Interim UM said the facility had no orders to go by. She again reviewed the resident's clinical records and verbalized that an order addressing the wound management system, and monitoring of the resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105332 If continuation sheet Page 5 of 9 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 11/15/2023 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 0635 surgical site could not be identified. Level of Harm - Minimal harm or potential for actual harm On 11/13/23 at 3:20 PM, the Assistant Director of Nursing (ADON) stated she was the interim DON from 10/19/23 until 11/12/23. She stated the resident returned to the facility from an acute care hospital on [DATE]. She explained that he was readmitted on the 3PM-11PM shift, and the process included a review of the resident's hospital discharge orders with the resident's Primary Care Physician. After confirmation/reconciliation of the orders, they would then be placed in the resident's Electronic Medical Record (EMR), and a head-to-toe assessment of the resident would be conducted by the admitting nurse, and the wound care nurse would be involved if there was a wound. The ADON stated the wound care nurse contacted the resident's surgeon for clarification regarding discontinuation of the wound vac. She stated the wound care nurse monitored the resident's wound vac, but she did not know where documentation would be. She could not say when/ who monitored the wound management system, and the resident's surgical site. Review of the resident's physician orders conducted with the ADON revealed orders dated 11/13/23 with start date of 11/14/23, for daily wound care, with dry dressing daily and PRN, and to discontinue wound vac when battery depletes. Record review revealed the orders were entered by the ADON on 11/13/23 at 3:07 PM, after surveyor conducted an interview with the LPN/Interim UM. Residents Affected - Few On 11/13/23 at 4:21 PM, Registered Nurse (RN) A, resident #19's primary nurse, stated there were no physician orders in place to monitor the resident's wound management system. She verbalized she was told by the wound care nurse not to touch the vac. On 11/14/23 at 10:40 AM the ADON reiterated that on admission, hospital discharged instructions would be reviewed by the admitting nurse. Orders would be reviewed with the physician, then placed in the residents' EMR. She stated that in the clinical morning meetings, all new admissions/readmissions, plan of care, outcome of their care, physician's orders are reviewed, and the hospital discharge summary would also be reviewed, to ensure carry over of orders, and treatments were done. The ADON stated instruction from resident #19's hospital discharge summary regarding the wound management system should have been carried over to the facility's EMR, for it to populate on the Treatment Administration Record (TAR), so nurses could be aware, and monitor the system as per the hospital discharge summary. On 11/14/23 at 10:59 AM, the wound care nurse stated that on 10/31/23 resident #19 was admitted with no orders for wound vac dressing changes. She stated she called the hospital several times with no response, until 11/02/23. At that time, she was told to leave the wound vac in place until the battery discharged , then replace it with dry dressing. She stated that she rounded on the resident daily except on Saturday and Sunday, and it was her responsibility to check on the wound vac. She verbalized she did not document any note regarding checking/ monitoring of the wound vac. When asked how nurses were made aware of the need to monitor the wound management system, the wound care nurse said nurses should check on the wound management system on the weekend, and information should be given in the shift-to-shift report. The wound care nurse said it would probably have been more appropriate to have the order populate on the resident's TAR. She verbalized that review of the hospital discharge summary was done, to guide care of the resident. However, the wound care nurse said she did not recall seeing orders/directions for the wound management system/wound care in the discharge summary. The wound care nurse recalled the resident's surgery was done on 10/28/23, and as per discharge instructions should be discontinued in 14 days, which would have been 11/11/23. The facility's policy Wound Treatment Management implemented 11/03/20, and reviewed/revised on 11/23/22, indicated that the facility would promote wound healing of various types of wounds, and read, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105332 If continuation sheet Page 6 of 9 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 11/15/2023 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 0635 Level of Harm - Minimal harm or potential for actual harm wound treatments will be provided in accordance with physician orders .In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders .Treatments will be documented on the Treatment Administration Record or in the electronic health record. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105332 If continuation sheet Page 7 of 9 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 11/15/2023 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 0776 Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. 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 ensure physician orders for stat x-rays were obtained in a timely manner for 1 resident of a total sample of 5 residents, (#1). Residents Affected - Few 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, mood (affective) disorder, nondisplaced fracture of the base of neck of the right femur, and chronic pain. Review of the resident's eInteract change in condition form dated 11/12/23, revealed the resident experienced uncontrolled pain, had bruises to her right eye and right forehead, and pain to her right shoulder. The document indicated the physician was notified on 11/12/23 at 8:40 AM, and recommended x-rays 3 views. Review of the resident's physician orders, revealed order dated 11/12/23 for two view x-rays of the right shoulder and facial bone. A progress note documented on 11/12/23 at 10:06 PM by the weekend Supervisor read, (name of company) called X 2 regarding stat x-ray to be done. Spoke with [name] regarding eta (expected time of arrival). Stated that they are closed, and the x-ray will be done in the morning. Call placed to MD. ARNP (Advance Registered Nurse Practitioner) made aware of same. Res (resident) granddaughter notified. Requested resident be transferred to the hospital. ARNP [name] notified of same .Ecchymotic area and swelling to right Eye. Prn (as needed) (medication) given for c/o (complaint off) pain to right shoulder. On 11/15/23 at 1:33 PM, the weekend Supervisor recalled that on 11/12/23, resident #19's primary nurse on the 7 AM-3 PM shift reported to her that the resident's CNA told her the resident had a bruise on her head, had a bump to her right forehead, and a bruise to the side of her right eye. The Weekend Supervisor recalled she advised the nurse to assess the resident, and notify the physician, and family. She verbalized the physician gave order for stat x-ray, and when she noticed that the x-ray company had not shown up, she called back, and placed a second stat order at approximately 2:00 PM. She stated that as the evening progressed, the Radiology company still had not shown up, and after about two hours she called again, and was advised by the company they were not coming out that day and would be at the facility in the morning 11/13/23. The Weekend Supervisor stated she notified the physician, and notified the family, who wanted the resident sent out to the hospital. She said the resident was transferred to the hospital on [DATE] at approximately 11:45 PM. The Weekend Supervisor stated that when an order was stat it indicated it should be done now, and usually the company would call and say what time they would be coming in to do the x-ray. She said they showed up on 11/13/23. On 11/15/23 at 2:22 PM, the resident's Primary Care Physician (PCP) stated, stat for her means the order/treatment should be done within 2 to 4 hours. On 11/14/23 at 3:25 PM, RN A recalled that on 11/12/23, the resident's assigned CNA called her to observe the resident. Observation showed a bruise to the side of the resident's right eye, and right (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105332 If continuation sheet Page 8 of 9 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 11/15/2023 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 0776 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few forehead approximately the size of a penny. RN A stated she notified the Supervisor around 8 AM- 8:30 AM, called the physician, and received recommendation for X-ray of the shoulder. RN A verbalized the resident was in the dining room during the day for the fall program, and at around 1 PM-1:30 PM she checked, and the resident's right eye was swollen shut. She stated the resident was sent out to the hospital on the 3 PM-11 PM shift. Review of the physician's orders for resident #19 conducted with RN A revealed an order dated 11/12/23 at 2:01 PM for X-ray 3 views. RN A reported the X-ray was completed on 11/13/23 at 7:15 AM, and the result showed shoulder low grade AC joint separation. The facility's policy Radiology and other Diagnostic Services and Reporting implemented 11/2020, and reviewed/revised 11/29/22, read, The facility must provide or obtain radiology and other diagnostic services when ordered by a physician, physician assistant, nurse practitioner or clinical nurse specialist in accordance with state law. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105332 If continuation sheet Page 9 of 9