Inspection·October 20, 2022

F 0620 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. Based on record review and interview, the facility failed to ensure residents were not asked to waive facility's liability for losses of personal property as a condition for admission for 122 residents currently residing in the facility. Findings: Review of the facility's admission agreement/contract revealed the facility required residents to waive facility's liability for losses of personal property. Section 9a of the contract read, .The Facility will also offer the Resident with a private closet and a locked storage space in his/her room. The facility will only be responsible for failing to take reasonable care in protecting residents' personal property including to protect personal property specifically placed into safekeeping at the facility, with the Facility's consent and in accordance with the Facility established policies or in the Resident's locked storage space. Facility shall insure against loss of valuable items (such as money or jewelry) only if such items are deposited with the management or placed in locked storage provided to the Resident by the facility. The facility's contract noted only only money and jewelry as valuable, and did not consider what was valued or sacred to the resident. Section 9 b of the contract read, Except as otherwise provided herein, the Resident and the Resident Representative assume all responsibility for the Resident and the Resident's personal property and hereby release and agree to hold harmless the Facility, its Board of Directors, officers, agents and employees from any and all responsibility for the welfare of the Resident, for injury, or death, or for damage of loss to any personal property. On 10/20/22 at 7:30 PM, the Business Office Manager and the Director of Community Liaison stated the facility was purchased by another company on 4/1/22. The Director of Community Liaison stated she reviewed admission contracts with newly admitted residents within 48 hours of admission. She did not provide a reason why there was a waiver for lost or damaged personal property in the admission contract. The contract was reviewed and she could not explain why the residents' personal property was not safe in their room in the facility. On 10/20/22 at 7:57 PM, the Facility Administrator stated when the new company took over, all the residents signed a new admission contract. The Administrator could not explain why the waiver for the facility's liability for the loss or damage of resident property, was in the facility's admission agreement. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105430 If continuation sheet Page 2 of 10 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 105430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rehabilitation Center of Winter Park 1700 Monroe Ave Maitland, FL 32751 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of resident #94's clinical records noted he was admitted to the facility on [DATE], with his most recent readmission on [DATE]. His diagnoses included acute respiratory failure with hypoxia, bipolar disorder, Parkinson's Disease, dementia, psychotic disorder, and schizoaffective disorder. Residents Affected - Some A physician's order dated 6/06/22 noted oxygen [O2] 2 Liters/per minute [LPM] via nasal cannula [NC] continuously. The resident's quarterly MDS assessment with ARD 9/13/22 revealed the resident's cognition was intact with a Brief Interview for Mental Status (BIMS) score of 14/15. Section O: Special Treatments, Procedures, and Programs indicated the resident had not received O2 while a resident of the facility, and within the last 14 days. Review of the resident's clinical records for the period 9/01/22 to 10/19/22 revealed his O2 saturations were between 93% to 99% on room air and on O2. 5. Resident #108 was admitted to the facility on [DATE] with her most recent readmission on [DATE]. Her diagnoses included diabetes type II, cerebral palsy, anemia, asthma with acute exacerbation, and post traumatic stress disorder. A physician order dated 7/28/22 read, O2 2 LPM continuous via NC. The resident's quarterly MDS assessment with ARD of 9/16/22 revealed the residents' cognition was intact with a BIMS score of 15/15. Section O: Special Treatments, Procedures, and Programs indicated the resident had not received O2 while a resident of the facility, and within the last 14 days. On 10/20/22 at 11:40 AM, the MDS Assistant stated MDS assessments were conducted by doing a seven day look back, which included review of the residents' medical records, observations of the residents, and interview with the resident/responsible party and staff as needed. Residents #94's and #108's quarterly MDS assessments, and their relevant clinical records were reviewed with the MDS Assistant. She acknowledged the MDS quarterly assessment with ARD 9/13/22 for resident #94, and ARD 9/16/22 for resident #108 did not document the residents received O2 therapy. The MDS Assistant acknowledged the residents were on O2 therapy during the look back period and the assessments were not accurate. 6. Resident #123 was admitted to the facility on [DATE] with previous admission on [DATE] from a skilled nursing facility with diagnoses of sepsis due to Escherichia Coli, acute and chronic respiratory failure with hypoxia, and ischemic heart disease. Review of skilled nursing facility (SNF) history and physical dated 5/25/22 revealed the resident was on hospice care services. On 10/19/22 at 11:24 AM, the Administrator stated resident #123 was a long term care resident on hospice services. Review of the resident's physician order dated 5/24/22 revealed hospice care. A physician progress note dated 6/15/22 at 12:59 PM read, follow up on chronic conditions, now on hospice care. A review of the resident's care plan revealed a focus for hospice care initiated on 6/7/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105430 If continuation sheet Page 3 of 10 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 105430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rehabilitation Center of Winter Park 1700 Monroe Ave Maitland, FL 32751 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the resident's MDS Significant Change assessment dated [DATE] Under Section J inaccurately showed No as the answer to Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? Section O of the assessment showed no documentation for Hospice care. In an interview and review of resident #123 medical record with MDS assistant on 10/22/22 at 6:42 PM, noted she had been working as MDS assistant for less than 3 months and was still learning how to do significant change MDS assessments. She stated information was obtained from documentation in the resident's medical record, and interviews with staff and residents. She was unsure if there was an audit or check system to ensure accuracy of assessments. On 10/20/22 at 6:55 PM, the Administrator stated ultimately, me and the DON oversee MDS assessments at the facility level. She stated they did not have a MDS director and Corporate RN's usually signed for the accuracy of the assessments. The Centers for Medicare & Medicaid Services Long Term Care Facility Resident Assessment Instrument 3.0 Manual Version 1.17.1 October 2019 Section O read, The intent of the items in this section is to identify any special treatments, procedures, and programs that the resident received during the specified time periods Oxygen therapy: Code continuous or intermittent oxygen administered via mask, cannula. Review of the Facility CLINICAL SERVICES POLICY AND GUIDELINES FOR IMPLEMENTATION SUBJECT RESIDENT ASSESSMENT NUMBER 636 dated 11/2017 revealed PURPOSE: to utilize the Resident Assessment Instrument (RAI) to conduct comprehensive significant change of condition and quarterly assessments, and others as required, to reflect the resident's status and identify the resident's preferences and goals of care Further review of the policy revealed, GUIDELINES: 9. The assessments will be conducted by individuals with the knowledgeable to complete an accurate assessment of relevant care areas and are knowledgeable about the resident's status, physical, mental and psychological needs, strengths and areas of decline. 10. Assessments will be coordinated by a registered nurse. 11. Individuals who complete a portion of the assessment will sign and certify the accuracy of that portion of the assessment. Based on observation, interview and record review, the facility failed to ensure sections C, D and E of the Minimum Data Set (MDS) assessments were accurately completed for 3 of 8 residents reviewed, (#17, #23 and #117), failed to accurately complete the MDS assessment pertaining to oxygen use for 2 of 3 residents reviewed for oxygen therapy (#94 and #108), and failed to ensure accurate assessment for 1 of 5 residents reviewed for comprehensive assessment accuracy, (#123), of a total sample of 64 residents. Findings: 1. Review of resident #17's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included cerebrovascular disease, major depressive disorder, B-cell lymphoma, and polyarthritis. Review of the quarterly MDS assessment with Assessment Reference Date (ARD) of 7/17/22 revealed resident #17 was not interviewed for the Brief Interview for Mental Status (BIMS) in Section C or the Mood assessment in Section D. The MDS showed both sections were completed by interviewing staff instead of the resident. Review of the previous quarterly MDS dated [DATE] revealed a score of 15, which indicated he was cognitively intact. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105430 If continuation sheet Page 4 of 10 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 105430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rehabilitation Center of Winter Park 1700 Monroe Ave Maitland, FL 32751 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. Review of resident #23's medical record revealed she was readmitted to the facility on [DATE]. Her diagnoses included anxiety disorder, schizoaffective disorder, chronic obstructive pulmonary disease, and heart failure. Review of the quarterly MDS assessment with ARD of 7/24/22 revealed resident #23 was not interviewed to obtain her BIMS score in Section C and her Mood assessment in Section D. The MDS showed both sections were completed by interviewing staff instead of the resident. Review of the quarterly MDS with ARD of 4/23/22 and the 5-day with ARD of 2/14/22 revealed a score of 13 and 15, respectively, which indicated she was cognitively intact. 3. Review of resident #117's medical record revealed she was readmitted to the facility on [DATE] with diagnoses of stroke and type 2 diabetes. Review of the quarterly MDS assessment with ARD of 9/23/22 revealed resident #117's BIMS score was 15 which indicated she was cognitively intact. Section E titled Behaviors of the quarterly MDS was not completed. On 10/20/22 at 5:20 PM, the MDS Coordinator explained Sections B, C, D, E and Q of the MDS assessments were completed by the Social Services Director (SSD). She indicated the facility did not have a SSD at the moment. She said, at some point, the sections required to be completed by the SSD were not being done because there was not anyone in the facility that could complete them. The MDS Coordinator noted they did not have a staff person in the facility to provide oversight of the MDS assessments but explained there were 2 corporate Registered Nurses who assisted and signed the MDS assessments. She confirmed resident #17 and #23's sections C and D of the quarterly MDS were not accurately completed. She also confirmed section E of the quarterly MDS for resident #117 was not completed as required. The MDS Coordinator did not know why the SSD did not assess residents #17 and #23. She stated it was important to assess the competency of the residents for their provision of care. On 10/20/22 at 6:52 PM, the Administrator explained they did not have a designated person in the facility overseeing the MDS assessments. She said she was aware of the incomplete and inaccurate MDS assessments, and added, that was part of the problem why the SSD is no longer here. She explained they had been trying to catch up with the assessments since the SSD left. She noted it was important to complete the assessments correctly in order to provide the care each resident needed. She explained they realized there was an issue and were trying to work on correcting it. The Administrator indicated the Director of Nursing (DON) helped a little with MDS assessments. The Administrator stated that she and the DON were ultimately responsible for the residents' assessments. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105430 If continuation sheet Page 5 of 10 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 105430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rehabilitation Center of Winter Park 1700 Monroe Ave Maitland, FL 32751 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 0693 Level of Harm - Minimal harm or potential for actual harm Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview and record review, the facility failed to follow physician ordered tube feedings for 1 of 2 residents receiving tube feeds, in a total sample of 64 residents, (#119). Residents Affected - Few Findings: Review of resident #119's medical record revealed his diagnoses included intracerebral hemorrhage, and dysphagia. A physician's order dated 10/5/22 read, Osmolite 1.5 at 60 milliliters (ml) per hour for 20 hours to start at 2 PM and turned off at 10 AM, the next morning. On 10/17/22 at 11:12 AM, resident #119 was observed in bed and his tube feeding pump was noted to be off. On 10/19/22 a new physician order for tube feedings read, Osmolite 1.5 at 80 ml for 12 hours. The tube feed pump was to be turned on at 7 PM and turned off at 7 AM, the next morning. On 10/19/22 at 5:38 PM, the resident was observed sitting up in bed. The tube feeding pump was on and the formula was infusing at a rate of 60 ml per hour. At 5:41 PM, the resident's direct care Licensed Practical Nurse, (LPN) C observed the tube feeding pump and acknowledged the tube feed formula infused at a rate of 60 ml per hour. LPN C reviewed the physician's order on the electronic Medication Administration Record (MAR) and reported the tube feeding orders had been changed to 80 ml per hour. She said she was unsure when the 80 ml per hour feeds were to start. She explained LPN B had received the new order by telephone and entered it electronically to start at 11:00 PM this evening but the physician ordered it to start at 7:00 PM and stop at 7:00 AM the next morning. She added LPN B did not inform her of the changed order during shift change report. She said she would get clarification for the tube feeding order from the Director of Nursing, (DON) and/or the physician. On 10/20/22 at 12:41 PM, the DON explained LPN B started the tube feeding pump at 2 PM yesterday and later in the afternoon, she received a telephone order from the physician to increase the tube feedings to 80 ml per hour with the start time of 7 PM and stop at 7 AM, the next morning. The DON stated LPN B should have turned off the the tube feed pump when she received the new order and informed the oncoming nurse of the changes at shift report. The DON acknowledged LPN B had entered the new tube feed orders incorrectly in the electronic system. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105430 If continuation sheet Page 6 of 10 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 105430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rehabilitation Center of Winter Park 1700 Monroe Ave Maitland, FL 32751 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure oxygen [O2] therapy was administered per physician's order for 1 of 4 residents reviewed for O2 therapy of a total sample of 64 residents, (#94). Residents Affected - Few Findings: Review of resident #94's clinical records noted he was admitted to the facility on [DATE], with his most recent readmission on [DATE]. His diagnoses included acute respiratory failure with hypoxia, bipolar disorder, Parkinson's Disease, dementia, psychotic disorder, and schizoaffective disorder. A physician's order dated 6/06/22 read, oxygen [O2] 2 Liters/per minute [LPM] via nasal cannula [NC] continuously. A progress note dated 6/07/22 read, on oxygen 2 L continuously. On 10/18/22 at 9:55 AM, resident #94's oxygen was noted at 3 LPM. On 10/18/22 at 10:09 AM, Licensed Practical Nurse [LPN] D stated resident #94 had physician orders for O2 at 2 LPM. LPN D observed the resident's oxygen setting and acknowledged it was set at 3 LPM, and not 2 LPM as ordered. LPN D verbalized that O2 was considered a medication, and nurses were the ones to monitor the resident's O2 settings. She explained that at the start of her shift, she reviewed physician orders for her assigned residents, and verified O2 settings to ensure O2 was infusing as ordered. The LPN acknowledged she did not verify O2 settings for resident #94. On 10/18/22 at 10:35 AM, the Director of Nursing [DON] stated O2 was considered a medication, and a physician's order was required for administration. The DON stated that since O2 was a medication, it had to be associated with the five rights of medication administration, which included the right dose. She explained if the resident was on O2 continuously, the expectation was that the O2 would be monitored throughout the shift to ensure it was being administered as per the physician's order. Record review of resident #94's physician orders conducted with the DON revealed an active order for O2 at 2 LPM continuously. This was confirmed by the DON. The resident's care plan At risk for impaired gas exchange and shortness of breath related to acute respiratory failure with hypoxia created on 4/18/22, with revision on 9/21/22 included intervention, Oxygen as ordered. The facility's policy Oxygen Therapy with effective date of 4/01/22, read, Oxygen therapy is administered per MD [Medical Doctor] order or as an emergency measure until an order can be obtained. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105430 If continuation sheet Page 7 of 10 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 105430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rehabilitation Center of Winter Park 1700 Monroe Ave Maitland, FL 32751 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure medications were accurately labeled on the South/Keys unit medication cart for 1 of 6 residents reviewed for medication administration of a total sample of 64 residents, (#53). Findings: Medication administration pass was observed on South/Keys unit on 10/17/22 at 12:10 PM, with Licensed Practical Nurse (LPN) A. LPN A confirmed she administered Levetiracetam 250 milligrams (mg) tablet by mouth to resident #53. Observation of the medication label listed on blistex package revealed label instructions for Levetiracetam 250 mg tab give 1 tab via gastrostomy (G)-tube twice a day. Review of resident #53's physician orders with LPN A revealed order dated 8/8/22 that read, may crush meds all crushable meds and put in applesauce, pudding, or yogurt every shift. Observation of blister card packs located in the medication cart with LPN A for resident #53 showed medication labels for Clopidogrel Bisulfate Tablet 75 mg give 1 tablet via G-Tube in the evening, and Escitalopram Oxalate tablet 10 mg give 1 tablet via G-Tube in the evening. LPN A stated that the resident's medications were to be crushed and acknowledged the label on the blistex cards did not match the physician order for the right route. She stated in order for the blistex cards to have the correct label, each order would have to be discontinued in the computer and the right route entered. Once it is updated in the computer then it is linked to the pharmacy system. She stated it would have been the nurse's responsibility who received the new medication order on 8/8/22. She stated she received education on medication administration, physician orders within the last month or two. On 10/17/22 at 1:21 PM, the Director of Nursing (DON) stated nurses must follow the physician orders when administering medications. She stated if a new order was received, it was to be updated in electronic system. The DON noted that new orders were reviewed in the morning clinical meetings and the expectation was for nursing clinical staff to follow the 5 rights for medication administration. Review of the facility's Medical Labeling Policy dated April 1, 2022 revealed Purpose: To ensure that all medications within the facility are labeled and are labeled in a consistent manner. Policy: All medications dispensed and/or provided by the Provider Pharmacy and/or another pharmacy will be labeled in accordance with all federal and state regulations. Review of the facility's Medication Preparation for Dispensing Policy section 6: Administration of Medications no date showed Policy All medications will be prepared (blister card, vials, Artromick Box) and administered in a manner consistent with the general requirements outlined in this policy Procedure G. Prior to Medication Administration: 1. Verify each medication preparation that the medication is the RIGHT DRUG, at the RIGHT DOSE, the RIGHT ROUTE, at the RIGHT RATE, at the RIGHT TIME, for the RIGHT CUSTOMER. Review of POLICY AND GUIDELINES FOR IMPLEMENTATION ADMINISTERING MEDICATIONS dated April 1, 2022 revealed, Protocol: 6. The individual administering the medication must check the label to verify the right medication, right dosage, right time and right method of administration before giving the medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105430 If continuation sheet Page 8 of 10 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 105430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rehabilitation Center of Winter Park 1700 Monroe Ave Maitland, FL 32751 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 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, record review, and interview, the facility failed to follow the menus to meet the residents needs and choices for 4 of 64 sampled residents, (#113, #127, #432, and #433). Residents Affected - Some Finding On 10/17/22 at 9:28 AM, resident #113 was reclining in bed, listening to music. He stated he did not get the meal that was noted on his meal tray ticket. The tray ticket indicated he would receive French Toast. The resident stated he did not get any French Toast and he had to go to the kitchen to get the French Toast himself. He explained he did not eat pork and staff were aware, but they had sent him pork sandwiches in the past. He stated he had a problem with his meals daily as they were never correct. On 10/17/22 at 10:31 AM, Certified Nursing Assistant, (CNA) E stated resident #113 often went to the kitchen himself when his meal tray did not have the right food. Review of the lunch menu for 10/17/22 revealed the residents would receive Swedish meatballs with gravy, egg noodles, cauliflower with pimento, dinner roll with margarine, chilled peaches and beverage of choice. On 10/17/22 at 12:39 PM, on the Rehab Wing, resident #433 was in bed eating lunch. He pointed to his meal tray ticket and stated he did not get dinner roll. The kitchen was observed and the kitchen staff were in the middle of tray line. There was a pan of dinner rolls on the steam table. The Registered Dietician (RD) was informed resident #433 did not get dinner roll. The RD went to the resident's room and asked him if still wanted the roll and the resident replied yes. The RD then went into resident #432's room and there was no dinner roll on the meal tray. Resident #432 stated she had just started to eat. The RD checked several rooms on the Rehab Wing and it was discovered none of the residents on the Rehab Wing had received dinner rolls. On 10/17/22 at 12:57 PM, resident #127 was in his room but did not have a lunch tray. The resident stated he had finished with Therapy about 20 minutes ago. There were 2 CNAs in the hallway and they were asked about resident #127's lunch tray. The CNAs looked in the meal tray cart and said resident #127's lunch tray was not on the cart. One of the CNAs went to the kitchen and returned with a lunch tray for resident #127 and said the kitchen could not find the resident's meal tray ticket. On 10/17/22 at 1:11 PM, the cook, 2 dietary aides and the kitchen supervisor were interviewed. The staff stated the last person on the tray line was supposed to check the trays for completeness. The supervisor stated when she came into the kitchen staff had already started the lunch tray line but the dinner rolls were still in the oven. The supervisor stated that the Rehab Wing was first to be served. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105430 If continuation sheet Page 9 of 10 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 105430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rehabilitation Center of Winter Park 1700 Monroe Ave Maitland, FL 32751 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain consent for administration of a Coronavirus Disease 2019 (COVID-19) vaccine for 1 of 5 residents reviewed for immunization out of a total sample of 64 residents, (#106). Findings: Review of resident #106's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease and dementia. The record showed resident #106's spouse was the responsible party. Review of the Minimum Data Set (MDS) quarterly assessment with Assessment Reference Date of 9/15/22 revealed the facility did not attempt to complete a Brief Interview for Mental Status for resident #106 due to severely impaired cognition. Review of resident #106's immunization record revealed the facility administered a booster for COVID-19 on her left deltoid on 12/16/21. No evidence of education or consent from resident #106's responsible party was found in the medical record. On 10/20/22 at 6:05 PM, the Staff Development nurse stated the resident or her responsible party was required to sign a consent every time a resident was vaccinated. At 8:19 PM, she indicated she did not find resident #106's signed consent form for the third COVID vaccine administered on 12/16/21. Review of the policy titled COVID - Vaccination Program (Florida) dated 4/01/22 revealed all residents/representatives would receive education on the COVID-19 vaccine in a manner they can understand to include the FDA EUA Fact Sheet. The policy read, If the vaccine involves two doses .resident/representatives will be provided with the same counseling .before requesting consent for the second dose, and The facility will maintain documentation for all residents .on COVID-19 vaccination. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105430 If continuation sheet Page 10 of 10