Inspection·June 14, 2023

F 0580 representative about treatments. 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: 105430 If continuation sheet Page 2 of 12 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 06/14/2023 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a baseline care plan was developed within 48 hours of admission for 1 of 3 residents reviewed for pressure ulcer care out of a total sample of 16 residents, (#1). Findings: Review of resident #1's medical record revealed he was admitted to the facility on [DATE] with diagnoses of urinary retention, multiple myeloma, and dementia. The resident was transferred to an acute care hospital on [DATE]. Review of the Medicare 5 Day/Discharge Return Not Anticipated Minimum Data Set assessment dated [DATE] noted the resident had severe cognitive impairment, required extensive assistance with activities of daily living, had an indwelling urinary catheter and utilized a wheelchair for mobility. Review of resident #1's medical record revealed a Baseline Care Plan that included only his name, admission date, admission time, allergies and code status. The areas directing his care for dietary, therapy, safety, activities of daily living, skin issues, discharge plans, goals were all blank. The form was not signed or discussed with the resident or representative. Review of resident's comprehensive care plan revealed grooming and transfer deficits were initiated on 05/10/23 and cognitive/social and sensory stimulation, and risk for malnutrition were initiated on 05/24/23 (8 days after transfer to the acute care hospital). On 6/13/23 at 5 PM, the Director of Nursing (DON) and Regional Nurse Consultant (RNC) confirmed the baseline care plan had not been completed. The DON explained the baseline care plan was to be completed by the nursing staff within 48 hours. The RNC said, that a copy of the completed baseline care plan should then be given to the resident and/or responsible party. Review of the Facility's Baseline Care Plan, Comprehensive Care Plan and Ongoing Care Plan Updates Policy, dated April 1. 2022, read, Policy Statement: (Facility Name) will follow a uniform process for initiating the baseline care plan upon admission . Baseline Care Plan: . The baseline care plan will: Be developed within 48 hours of a resident's admission; The admitting nurse will initiate the baseline care plan . written summary of the baseline care plan must be provided to the resident and/or the representative by completion of the comprehensive care plan . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105430 If continuation sheet Page 3 of 12 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 06/14/2023 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 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 observation, interview, and record review, the facility failed to prevent a physically impaired resident from exiting the facility unsupervised and failed to provide adequate supervision and a secure environment for 1 of 3 residents reviewed for elopement, out of a total sample of 16 residents, (#4). Findings: Review of the medical record revealed resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] from an acute care hospital with diagnoses including aftercare following joint replacement surgery, displaced fracture of base of neck of left femur, repeated falls, abnormality of gait and mobility, cognitive communication deficit, compression of brain, and traumatic subdural hemorrhage with loss of consciousness. Review of the quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 3/01/23 revealed resident #4's Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. She required supervision for bed mobility, and extensive staff assistance for transfers, locomotion on and off unit, and toilet use. A significant change in status MDS assessment with ARD of 5/04/23 noted resident #4's BIMS score was 6 out of 15 which indicated severe cognitive impairment. The assessment noted resident #4 needed extensive assistance with all activities of daily living (ADL), had unsteady balance and was only able to stabilize herself with staff assistance. She used a wheelchair for mobility. A discharge MDS assessment with ARD of 4/23/23 revealed she sustained two falls since admission, one with major injury. Review of the resident's care plan revised on 5/08/23 showed impaired thought processes related to possible craniectomy. Interventions included Provide calm, safe, structured environment, and provide reassurance and emotional support. A care plan for behavior problem revised on 5/08/23 revealed the resident was impulsive, emotional and hyper [sic] fixated. Unaware of safety needs. The interventions included to, Discuss behavior with resident, watch for behavioral clues to understand. A craniectomy is a surgery done to remove a part of the skull in order to relieve pressure in that area when the brain swells. A craniectomy is usually performed after a traumatic brain injury. (Retrieved from www.healthline.com on 6/17/23). Review of Elopement Risk Evaluation forms dated 2/24/23, 3/01/23, 3/08/23, and 4/27/23 revealed resident #4's risk scores were 14, 10, 14, and 14 respectively. The form noted that, If the total score is 10 or greater, the resident should be considered to be at risk for elopement. Prevention protocols should be followed and documented on the care plan. The form dated 2/24/23 listed Encourage diversional recreational activities as safety measure implemented due to risk for elopement. There were no safety measures selected for the evaluations dated 3/01/23 and 3/08/23. The evaluation dated 4/27/23 listed Wander bracelet / roam alert as safety measure implemented. Review of a nursing Progress Note dated 5/08/23 showed there resident wanted to go home with her husband. Review of a Physician Progress Notes dated 5/15/23 read, patient is trying to transfer to ALF (Assisted Living Facility) by her brother who lives up north . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105430 If continuation sheet Page 4 of 12 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 06/14/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of a SBAR (Situation-Background-Assessment-Recommendation) Communication Form dated 5/27/23 read, Resident was agitated wanting a cigarette, resident was found outside by a staff member and returned to the unit. Resident was placed on a one on one. On 6/12/23 at 10:27 AM, resident #4 explained on the day she eloped from the facility, she first went to the smoking patio. She noted she was not a smoker, and another resident told her to go back inside because she did not belong there. She explained this remark made her cry and she went inside and headed to the front of the facility. She indicated she had seen other residents in scooters going in and outside the facility by the front door. She said she knew where the button to open the main door was located and since there was no one at the front desk, she pressed the button and opened the front door. She stated she was not going anywhere in particular, she just wanted to get out of here, still want out of here to be closer to family. On 6/12/23 at 11:03 AM, the Assistant Director of Therapy stated resident #4 was not ambulatory and pretty sick when she was admitted to the facility. He explained therapy had worked with her throughout her stay and she had progressed from total assistance with bed mobility and transfers to ambulating. He stated they began working on problem solving and at the time resident #4 left the facility, it was not safe for her to be out by herself. On 6/12/23 at 1:05 PM, the Director of Maintenance stated on Saturday 5/27/23 he came to the facility because a power outage triggered the emergency generator. He explained after the power returned and everything was back to normal, he left the facility. He recalled he drove away and as he approached the first stop sign, he saw resident #4 by the sidewalk in her wheelchair. He indicated he pulled his car over and came out to speak to her and she told him she wanted to smoke but no one would give her a cigarette. He indicated she was about 40 feet past the stop sign. He explained when he first saw the resident outside, he called the Administrator and asked if she was supposed to be out, and she told him no. He asked her how she get out and she told him she pushed a button and let herself out. He said he did not understand how she let herself out when the receptionist was at the front desk. He stated upon returning to the facility, there was a Certified Nursing Assistant (CNA) at the receptionist desk and her eyes got real big when he told her he found resident #4 outside. On 6/12/23 at 2:32 PM, during a telephone interview, resident #4's brother and Power of Attorney (POA) explained his sister had never left the facility by herself until another resident told her just go away and leave and she did. He stated he did not feel she would be safe outside in a wheelchair by herself. He indicated he did not know how she got out of the facility because someone always had to buzz you in or out and the facility did not explain it to him. He indicated his sister said she left through the gate, so he assumed it was the gate from the smoking patio. He was not aware she wanted to smoke again until that day. On 6/12/23 at 3:13 PM, CNA A explained she worked as receptionist on 5/27/23. She indicated she was responsible for letting visitors in and out. She stated someone was supposed to cover her for breaks but sometimes there was no one available. She noted at around 2:35 PM on 5/27/23, the power went out and the rehab unit entrance was used to enter and leave the facility during the power outage. She indicated she remained in the reception area directing visitors to the rehab unit entrance. She explained she received a call from the Administrator soon after the power went out asking her to to go to each unit and relay directions to the nurses. She recalled no one relieved her at reception because everyone was working in the power situation. She explained at around 3:35 PM, a CNA told her she was assigned to work with her. She indicated she stepped out of the reception area with the CNA and went to the rehab unit to talk to the nurse. She stated the power returned just as she got back to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105430 If continuation sheet Page 5 of 12 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 06/14/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the reception area. She recalled she was sitting at the receptionist desk, when the Director of Maintenance returned pushing resident #4 in the wheelchair. She reported she had no idea the resident had left the facility until the Director of Maintenance returned with her. On 6/12/23 at 4:05 PM, during a telephone interview, CNA B explained she was not familiar with resident #4 because she worked on a different unit than where resident lived. She indicated on 5/27/23 she worked a double shift and was taking her break at about 3:40 PM near the vending machines with view of the parking lot, next to the main entrance. She stated she saw a resident outside the facility, but there were always some residents out side and there was always someone sitting at the front desk watching the door. She noted she called the nurse supervisor and asked her to come outside to see if resident #4 was supposed to be outside. She indicated she did not see the supervisor come outside to check the resident by the time her break ended at approximately 3:50 PM. On 6/12/23 at 4:27 PM, during a telephone interview, Licensed Practical Nurse (LPN) C explained she was at the medication cart in the rehab unit on 5/27/23 when she received a phone call from CNA B informing her of a resident outside. She indicated she asked CNA B the resident's name, or the room number and the CNA said she did not know. She stated she left her medication cart and went outside to check. She stated CNA B told her the resident made a left then a right turn. LPN C recalled she went outside from the rehab side, looked outside but did not see anyone. She remembered as she returned to the facility, the nurse assigned to resident #4 called her and told her someone returned the resident. She stated she then performed a headcount of all the residents and called the Director of Nursing (DON). On 6/12/23 at 4:50 PM, during a telephone interview, LPN D indicated she was assigned to resident #4 on 5/27/23. She explained resident #4 was not ambulatory when readmitted from the hospital but started ambulating with therapy. She recalled that Saturday was a normal day for resident #4 and she noted no changes in her behavior during the day. She noted resident #4 spent her morning in bed and got out of bed when the power went out. She stated resident #4 was not a smoker, but she liked to be outside. She explained on the day of the incident, she was getting ready to administer medications when someone from activities brought resident #4 back to the unit and informed her the resident was found outside. She said resident #4 told her she wanted to smoke, and showed her how she was able to press the button at reception and exit the facility. LPN D stated resident #4 was not safe to be outside the facility and she could have been hurt. On 6/13/23 at 11:13 AM, the Social Services Director (SSD) explained she performed cognition assessments and confirmed resident #4's BIMS scores fluctuated from 14 to 6 then back to 14. She recalled resident #4 had brain surgery and after returning from the hospital, she started improving. She said the resident was more mobile, more active and looked happier. She was not aware resident #4 was a smoker and the resident's brother had not mentioned smoking either. On 6/13/23 at 3:43 PM, the Keys Unit Manager (UM) stated when resident #4 returned from the hospital, she was confused and required cues to perform various tasks. She indicated about 2 to 3 weeks prior to the elopement, she did a 360 and started to gain more independence, came to the nursing station, and asked. She noted resident #4 had never visited the smoking patio before the incident and she did not know she was a smoker. The UM recalled she asked resident #4 how she would have crossed the busy street and she stated she would have figured it out. The UM indicated it was not safe for the resident to be out there by herself. On 6/13/23 at 1:09 PM, the Administrator explained on 5/27/23 she received a frantic call from the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105430 If continuation sheet Page 6 of 12 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 06/14/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Maintenance Director informing her resident #4 was out side. She stated she learned the receptionist was not at the front desk and CNA B saw the resident outside but did not approach or question her. She indicated CNA A told her she did not tell anyone she was stepping away from the front desk and did not lock the main door. She indicated CNA A's rationale was with power outage, the door had not opened as she had pushed the button before and the door did not open. She explained the expectation was the receptionist did not leave the front desk unless someone was there to cover. She stated resident #4 should not have been outside alone because she had decreased safety awareness due to recent brain surgery. The Administrator explained resident #4 was not an elopement risk when assessed and the Elopement Risk Evaluation completed on 4/27/23 was incorrect. The DON stated the reason the score identified resident #4 as an elopement risk was the way the questions are worded that make you score high but she was not considered at risk. The Administrator said this could have been worse and the resident could have been hurt in the parking lot or the main road. Review of the Receptionist job description, not dated, revealed essential duties and responsibilities included, Maintains established departmental policies and procedures, objectives, quality assurance program, and safety standards. Review of the policy and procedure titled Elopement revised on 3/01/23 read, It is the policy of the facility to provide a safe and secure environment for all residents. The policy revealed its purpose, To assure the safety and security of all residents. To train and maintain staff awareness of the importance of resident safety and security. Review of the Facility Assessment Tool updated on 5/27/23 revealed the facility was able to care for residents with psychiatric/mood disorders including impaired cognition, post-traumatic stress disorder, anxiety disorder and behaviors that needed interventions. The document indicated the facility would identify and implement interventions to help support individuals with issues such as dealing with anxiety and care of someone with cognitive impairment. Care and services were individualized and personalized to each resident preference. The form listed the training staff received at New Hire Orientation and annually which included Elopement Drill and Procedure. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105430 If continuation sheet Page 7 of 12 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 06/14/2023 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview ad record review the facility failed to ensure 3 of 3 residents with physician ordered purred diets were provided with the foods listed on their meal ticket out of a total sample of 16 residents, (#10, #12, #14). Findings: Review of the Facility's 06/12/23 Lunch Meal read, Entree: Barbeque (BBQ) Chicken, Parmesan Chicken, Brussels Sprouts. Desert: Pineapple Tidbits. Alternate: Beef Hot Dog, Mashed Potatoes and Yellow Squash. 1. Review of resident #10's medical record revealed she was admitted to the facility on [DATE] with diagnoses of Epilepsy, Dysphagia or difficulty swallowing, Gastrostomy, and Functional Quadriplegia. Review of the resident's annual Minimum Data Set (MDS) assessment dated [DATE] noted she had a feeding tube and was on a mechanically altered diet - routine change in texture of food or liquids (e.g., pureed food, thickened liquids). Review of the physician orders showed no added salt diet, pureed texture. On 06/12/23 at 1:30 PM, an observation of resident #10's meal was conducted with the Kitchen Director. The meal ticket on her lunch tray revealed Pureed BBQ Chicken - 4 ounce (oz), Extra BBQ Sauce - 2 oz, Pureed Parmesan Bowtie Pasta - 4 oz, Gravy - 2 oz, Pureed Brussels Sprouts - 4 oz. Pureed Crushed Pineapple (Drained) - 4 oz. Iced Tea - 1 each and Pepper - 1 Packet. The food on her plate revealed no pureed parmesan bowtie pasta. The Kitchen Director stated he did not know why resident #10 had received mashed potatoes instead of pureed parmesan bowtie pasta. 2. Review of resident #12's medical record revealed she was admitted to the facility on [DATE] with diagnoses that included Malnutrition, Dysphagia, and Dementia. Review of the resident's annual MDS assessment dated [DATE] noted she was on a mechanically altered diet - routine change in texture of food or liquids (e.g., pureed food, thickened liquids). Review of the physician's orders documented Regular diet, Pureed texture, and Fortified foods with every meal. On 6/12/23 at 1:40 PM, an observation of resident #12's meal was conducted with the Kitchen Director. The meal ticket on her lunch tray revealed Pureed BBQ Chicken -4 ounce (oz), Extra BBQ Sauce - 2 oz, Fortified Mashed Potatoes - 4 oz, Pureed Parmesan Bowtie Pasta - 4 oz, Gravy - 2 oz, Pureed Brussels Sprouts - 4 oz. Pureed Crushed Pineapple (Drained) - 4 oz. Iced Tea - 1 each, Nutritional Treat - 1 each, Salt and and Pepper - 1 Each. The food on her plate revealed no pureed parmesan bowtie pasta and no nutritional treat which was confirmed with the Kitchen Director. The Kitchen Director did not explain why the resident had not received the pureed parmesan bowtie pasta and nutritional treat as indicated on the meal ticket. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105430 If continuation sheet Page 8 of 12 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 06/14/2023 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 0808 Level of Harm - Minimal harm or potential for actual harm 3. Review of resident #14's medical record revealed he was admitted to the facility on [DATE] with Parkinson's Disease, Dysphagia, Malnutrition, and Dementia. Review of his quarterly MDS assessment dated [DATE] noted he was on a mechanically altered diet, pureed food with thickened liquids. Residents Affected - Few Review of the resident's physician's orders documented Regular diet, Pureed texture, Fortified foods, Allow soft mechanical pleasure foods/snacks. On 06/12/23 at 1:45 PM, an observation of resident #14's meal was conducted with the Kitchen Director. The meal ticket on his lunch tray revealed Pureed BBQ Chicken - 4 oz, Extra BBQ Sauce - 2 oz, Pureed Parmesan Bowtie Pasta - 4 oz, Gravy - 2 oz, Fortified Mashed Potatoes - 4 oz, Pureed Brussels Sprouts - 4 oz. Pureed Crushed Pineapple (Drained) - 4 oz, Nutritional Treat - 1 each, Salt and and Pepper - 1 Each. The food on his plate revealed no pureed parmesan bowtie pasta, no pureed crushed pineapple(drained) 4 oz and no nutritional treat which was confirmed by the Kitchen Director. The tray contained chocolate pudding. The Kitchen Director had no explanation why the resident had not received the pureed parmesan bowtie pasta and nutritional treat as indicated on his meal ticket. He explained the chocolate pudding was in place of the pureed crushed pineapple. On 06/12/23 at 2 PM, the facility's [NAME] stated she had made both the regular parmesan bowtie pasta and the pureed parmesan bowtie pasta for the lunch meal. She was unsure as to why resident's #10, #12 and #14 had not not received the purred parmesan bowtie pasta. On 06/12.23 at 2:15 PM, Dietary Aide J explained she was on the middle of the tray line today. She explained it was the responsibility of the middle line person to ensure the ticket matched the items on the plate. When presented with the 3 residents' meal tickets and informed the 3 residents did not receive the pureed parmesan bowtie pasta, she had no answer as to why this had happened. She said the nutritional treats were on the line because she remembered seeing them. Review of the Facility's Accuracy and Quality of Tray Line Service, dated 01/17/2019, read, Policy: Tray line positions and set up procedures are planned for an efficient and orderly delivery system. All tray are checked by food service personnel for accuracy. Trays are also checked by the employees serving the trays before giving the tray to the individual. Procedure: . 4. The tray is checked to ensure that foods are served as listed on the menu . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105430 If continuation sheet Page 9 of 12 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 06/14/2023 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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure food brought in from outside of the facility for resident consumption was properly stored, labeled, and discarded to prevent food-borne contamination in 3 of 3 pantry refrigerators/freeze, (Palms/100 unit, Rehabilitation/200 unit, and Key/300 unit) and failed to ensure employee food was not stored with resident food in 2 of 3 unit pantries, (Keys/300 unit and Rehabilitation/200 unit). Residents Affected - Some Findings: On 06/12/23 at 3:30 PM, Certified Nursing Assistant (CNA) F was observed in the Keys Unit (300) pantry eating food she had heated up in the microwave oven. She stated Am I in trouble? I should be eating in the employee break room. On 06/12/23 at 3:35 PM, an observation of the Keys Unit (300) pantry was conducted with the Keys Unit Manager. She explained the 11 PM -7 AM shift was responsible for ensuring the unit's pantry and refrigerator/freezer were checked daily and were clean. She stated, All food for the residents were to be labeled with the resident's name, room number (#) and date placed in the refrigerator/freezer. The freezer contained a plastic bag with 2 Styrofoam containers containing food and 1 plastic container with lid. One of the Styrofoam containers had the resident's name and room # but no date. The other Styrofoam container and plastic container had no resident name, room # and no date. A Styrofoam cup with a straw through the lid which was frozen solid had no resident name, no room #, and no date. The refrigerator contained: an open bottle of Pepsi, Sprite and Kombucha with no resident name, room # and no date. Two Styrofoam cups were observed on the pantry counter. One of the cups had a straw through the cup's lid and the cup contained a small amount of brown fluid with no resident name, room #, and no date. The second Styrofoam cup contained a small amount of brown fluid with a straw laying on the top of the cup's lid with no resident name, room # and date. The Keys Unit Manager confirmed the findings and stated, The pantry needed to be cleaned and all food needed to be thrown out. On 06/12/23 at 4:30 PM, an observation of the Palms Unit (100) was conducted with Licensed Practical Nurse (LPN) G. The refrigerator contained a large clear plastic container with lid containing a salad. LPN G explained the salad belonged to her and she she was not supposed to have her food along with the residents' food. She said the 11 PM -7 AM staff were responsible for checking and cleaning the pantry. The refrigerator contained a plastic container containing food with no resident name, room # and no date. A plastic container with purple lid contained macaroni and cheese with no resident name, room #, and no date. A plastic container of salad and 3 small containers of salad dressing had no resident name, room #, and no date. LPN G confirmed the findings and stated, The unlabeled foods needed to be thrown away and the items in the pantry were for residents only. On 06/12/23 at 5 PM, an observation of the Rehabilitation (Rehab) Unit (200) pantry was conducted with the Rehab Unit Manager. The freezer contained a frozen solid plastic cup with lid labeled, mango juice blend with sticker Must Use By 05/23/23 (20 days outdated) with no resident name, room #, and no date. A second frozen solid plastic cup with lid which had been punctured and covered with white paper and foil was labeled mango juice blend with sticker, Must Use by 05/12/23 (31 days outdated) had no resident name, room # and no date. The Rehab Unit Manager stated the cup must have been used and then placed in the freezer. A 20 fluid (fl) ounce (oz) plastic bottle of water with no resident name, room # and no date. A plastic container with blue lid containing food which was frozen solid with no resident name, room #, and no date. A 17.6 oz plastic container with lid labeled Mini Cream Puffs with a piece of tape attached to the lid with hand written 3 PM -11 PM, 11 PM -7 AM shifts. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105430 If continuation sheet Page 10 of 12 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 06/14/2023 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 0813 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Rehab Unit Manager stated, Employee food should not be in the freezer with the residents food. Observation of the refrigerator revealed two 8 oz plastic bottle of salad dressing with no resident name, room #, and no date. A clear plastic container containing salad with 2 forks and a knife. The top container was upside down on the container (not sealed) and the container had no resident name, no room #, and no date. A small glass container with cover containing white rice which was dried out with no resident name, no room # and no date. There was a bag of lettuce which had started to turn brown had no label with the resident's name, room # and date. A small round glass container with red lid containing food with no resident name, room # and no date. A small brown bag contained two dried out looking pastries had no resident name, room # and no date. An opened 23.9 oz plastic bottle of liquid had no resident name, room # and no date. The Rehab Unit Manager confirmed the findings and stated, The pantry needs to be cleaned and all the food needs to be discarded. On 06/12/23 at 5:30 PM, the Director of Nursing (DON) explained the 11 PM -7 AM staff were responsible for checking the unit pantry refrigerators/freezers. She said, All resident food containers were to be labeled with the resident's name, room # and date placed in the refrigerator. On 06/13/23 at 10:30 AM, the Administrator and Regional Nurse Consultant explained all resident items were to be labeled and no employees were to have their food items in the pantry. Review of the Facility's Guidelines for Foods Brought from the outside by Family and Visitors Policy,dated -1/17/2019, read, Policy: . 6. Perishable food must be stored in re-sealable containers with tight fitting lids in the refrigerator. Containers will be labeled with the resident's name, the items name and the use by date. The date should be 5 days after the food is brought in . 8. The nursing and or food service staff or housekeeping staff must discard any foods prepared for the resident that shows obvious signs of potential foodborne danger (example mold) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105430 If continuation sheet Page 11 of 12 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 06/14/2023 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 0921 Level of Harm - Minimal harm or potential for actual harm Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, and interview, the facility failed to ensure a clean and safe environment for resident food storage in 1 of 3 pantry freezers (Keys/300 unit). Residents Affected - Few Findings: On 06/12/23 at 3:30 PM, an observation of the Keys (300 unit) pantry freezer was conducted with the Keys Unit Manager. She explained that the 11 PM -7 AM shift were responsible for cleaning the pantry and refrigerator/freezer. The base of the internal freezer compartment was covered with a red sticky substance. A plastic bag containing 2 Styrofoam containers containing food and a plastic container with food was stuck to the red substance. When the plastic bag was removed from the base of the freezer compartment, the freezer thermometer was stuck to the bag. The Keys Unit Manager confirmed the findings and stated, The freezer needed to be cleaned and resident food should not be stored in the freezer. 06/12/23 at 5:30 PM, the Director of Nursing (DON) said the 11 PM -7 AM staff were responsible for ensuring the refrigerators and freezers used to store resident food were clean. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105430 If continuation sheet Page 12 of 12