Inspection·February 15, 2024

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some resubmitted because the system prompted them with a message in red. He stated although the status read Screening in Process, LPN D's fingerprints expired on [DATE], therefore, she was eligible to work. The DON stated she did not receive notification of expiration of fingerprints for LPN D. On [DATE] at 3:12 PM, during a telephone interview, the Human Resources (HR) Director stated she had been in the HR role for less than 6 months and did not have previous HR experience. She explained she received week long training from the [NAME] President of HR. She indicated her responsibilities included onboarding new staff, running background checks, processing payroll, and working on various reports. She explained she checked the AHCA Background Screening website when new staff were hired by using the DON's credentials as she did not have her own. She explained the DON was the only person in the facility who received notifications or alerts from the AHCA Background system as she was the only one in the facility with access. She indicated in [DATE] the new Administrator signed a form requesting credentials for the facility's Background Screening account for her, but it was declined because he was not the Administrator on record. She shared she received only one email forwarded by the DON last September regarding an upcoming expiration of fingerprints due in October, but it was not for CNA C or LPN D. She said she mainly entered and reviewed the new employees Background Screening, not the existing employees. She stated she knew if fingerprints expired, the employee would be suspended and sent for fingerprinting. She explained on [DATE], the DON reviewed an employee file for disciplinary action and discovered 5 or 6 employees with expired fingerprints. On [DATE] at 12:17 PM, the [NAME] President of HR stated she was responsible for the overall HR Operations. She explained when she started working in May, she covered the HR Director role in the facility as they did not have anyone in that role. She explained during that time she assisted 2 facilities and received assistance from the DON and former Administrator with some of the tasks she was unable to complete. She said she was on survival mode at that point. She stated she used the former Administrator's credentials to access the AHCA Background Screening website. She explained the authorized registered users with AHCA Background Screening website received notifications when fingerprints were due to expire, as well as arrests and status change alerts. She mentioned in a perfect world, that person would get the report, review, and address it. She stated when the Initiate Resubmission was selected in the AHCA Background Screening website, the eligibility status changed from eligible to pending. She indicated before she initiated the resubmission, she printed the report showing the eligibility status, but the employee would continue to work during that process because he/she was eligible to work. She said when the fingerprints had not expired, technically that person is eligible and added, Most of the time it will come back clear. If not clear we remove the person from working, but if employee was eligible with fingerprints not expired, there is a fair assumption the employee is eligible. She stated during the time she worked in the facility she did not review the fingerprint expiration dates for existing employees. Review of the HR Manager job description revealed she was responsible for the overall administration, coordination and evaluation of the HR function at the facility level. The job description read, Implements all Human Resources Policies and Procedures. Manages facility employees on the provision of care and services rendered in accordance with professional standards, and in compliance with state and federal laws and regulations. Review of the facility policy and procedure titled Abuse Policy - FL dated [DATE] read, The objective of the abuse policy is to comply with the seven-step approach to abuse and neglect detection and prevention. One of the seven step approaches of the abuse policy was screening. The policy revealed employees were screened prior to working with residents. Screening components included verification of references, certification and verification of license and criminal background check. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105430 If continuation sheet Page 2 of 11 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to report an allegation of neglect to the Agency for Health Care Administration (AHCA) for one resident (#1) and failed to report an allegation of neglect timely to AHCA for one of three residents reviewed for abuse/neglect of a total sample of 9 residents, (#2) . Findings: 1. Review of resident #1's medical record revealed he was readmitted to the facility on [DATE] with diagnoses including injury of urethra, quadriplegia, muscle wasting and atrophy. Review of the Minimum Data Set (MDS) 5-day assessment with Assessment Reference Date of 12/26/23 revealed resident #1's Brief Interview for Mental Status (BIMS) score was 15 out of 15 which indicated intact cognition. Review of resident #1's care plan for Activities of Daily Living (ADL) self-care performance deficit was initiated on 11/14/23. The care plan revealed resident #1 required substantial/maximal assist of one staff member for toileting, bed mobility, bathing, personal hygiene and dressing and total assist for transfers using a mechanical lift device and two staff. The assessment noted no rejection of care necessary to obtain goals for his health and well-being. On 2/13/24 at 10:53 AM, resident #1 shared that last Monday, despite asking more than once, he did not receive personal care and was not transferred to his wheelchair until late afternoon. He stated he was frustrated and after the incident he spoke with the Unit Manager (UM) and filed a grievance. Review of the Monthly Grievance Log revealed resident #1 filed a grievance on 2/05/24. The Grievance Report read, Resident had concerns that he was not assisted out of bed or given a bed bath even after 2 PM in the afternoon. The form showed the investigation was assigned to the UM. The UM wrote, 2/4/24 4 PM Spoke with [resident #1's name] who said, it was not a big deal. Resident requested he be assisted out of bed after breakfast, before lunch. CNA (Certified Nursing Assistant) educated. CNA suspended. The form included, AHCA Reported Yes / No and No was selected. Review of the Incident Log for February 2024 did not include evidence of an abuse report submitted to AHCA. 2. Review of resident #2's medical record revealed he was admitted to the facility on [DATE]. Resident #2's diagnoses included cholecystitis, type 2 diabetes, and hemiplegia and hemiparesis following a stroke affecting the left non-dominant side. Review of the MDS annual assessment dated [DATE] revealed resident #2's BIMS score was 15 out of 15 which indicated intact cognition. The MDS assessment showed resident #2 required substantial/maximum assistance for toileting and personal hygiene, shower/bath self, and upper body dressing. The assessment noted no rejection of care necessary to obtain goals for his health and well-being. Review of resident #2's care plan revealed he required staff assistance with ADLs to promote potential for functional improvement and avoid deficit related to impaired mobility. The care plan was revised on 5/09/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105430 If continuation sheet Page 3 of 11 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 2/13/24 at 10:26 AM, resident #2 stated he filed a grievance recently regarding not receiving care one day last week. He explained during the 7 AM to 3 PM shift, CNA G provided care to his roommate but not to him. He stated about 6 weeks ago he had requested not to have CNA G assigned to him again. He explained CNA G would not shower him on his assigned days, and she provided water, mouthwash, or care to his roommate but not to him. He said she was not doing her job. He indicated CNA G was supposed to get him out of bed after morning care, but she did not always do it. He stated he mentioned his concern about CNA G during his care plan meetings and was told it would be taken care of. He shared he would ask CNA G to get the UM and she would not do it. He explained he had to wait until he was taken to the shower room to talk to the UM because her office was next to the shower room. He mentioned to the UM not to have CNA G assigned to him, but last week she was assigned to him again. Review of the Monthly Grievance Log revealed resident #2 filed a grievance on 2/05/24. The Grievance Report, written by Registered Nurse (RN) E assigned to him that day, read, Patient is upset with CNA, patient reports that he have not received any ADL care and that no one came in his room to clean him up today. Patient reports that he turned his light on at 2:30 PM . CNA [Name of Staff H] came in and picked up his tray and told him that she will be back in to clean him up and never returned. The form included, AHCA Reported Yes / No and No was selected. Review of the Incident Log for February 2024 revealed an immediate report was submitted to AHCA on 2/09/24. Review of the Nursing Homes Federal Reporting revealed the Immediate Report for resident #2 was submitted to AHCA on 2/09/24 and listed the event occurred on 2/09/24. The AHCA report was completed by the Director of Nursing (DON). The Background Information section included, On 2/9/24 at 11:30 AM [Administrator Assistant] - voiced concerns that grievance was an allegation of neglect to [name of Administrator and name of DON]. On 2/13/24 at 2:26 PM, the Social Services Director (SSD) stated she was the Grievance Officer, and the DON was the Abuse Coordinator. She explained all grievances were discussed daily in the morning and standdown meetings. She indicated if a grievance was an abuse allegation, they reported it to the State following the appropriate timeframes, which was up to 2 hours for abuse and within 24 hours if neglect. She stated the UM spoke with resident #1 who said it was not a big deal, but CNA G was educated and suspended. The SSD stated she received this complaint directly from resident #1 when he called the facility's main number, and the call was transferred to her. The SSD explained residents #1's and #2's grievances were received the same day and both were reported to the State. On 2/14/24 at 11:08 AM, RN E explained one day last week resident #2 had his call light on and she answered it. She recalled resident #2 told her he had been wet for a while. She stated she asked him who his CNA was. She explained he responded it was CNA H and when CNA H picked his meal tray up, he told her he needed to be changed and she told him she would return to change him but never did and it had been a few hours. She recalled she turned the call light off and went to the nursing station and saw CNA H sitting there. She stated she asked CNA H why she did not return to change resident #2 and her response was he was not her resident, and she was not assigned to him. RN E indicated she looked at the assignment board and noticed CNA G was assigned to resident #2. She stated she clarified with resident #2 his assigned CNA was CNA G and he told her CNA G could not be assigned to him. She mentioned she did not ask him why and told CNA H to provide care, which she did with the incoming 3-11 PM CNA. She stated she returned to his room with a grievance form, but resident #2 could not complete it because he could not use his right hand, so she completed the form for him, and he signed it. She explained she gave the completed form to the SSD. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105430 If continuation sheet Page 4 of 11 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 2/14/24 at 12:23 PM, the UM explained last week they received two grievances involving the same CNA. She confirmed CNA G was assigned to residents #1 and #2 during the 7 AM to 3 PM shift on 2/05/24. She indicated CNA G had already left for the day when she learned about the issue from the staff that Monday. The UM said she texted the CNA and told her to return to the facility to assist with care and transfer of resident #1. She indicated resident #1 came to her the next day in his wheelchair and told her CNA G did not get him out of bed during the shift and she completed a grievance form for him. The UM stated she was aware CNA G was not supposed to be assigned to resident #2. The UM recalled she had written a grievance from resident #2 within the last 90 days where he requested CNA G not to be his assigned to him, but he would not elaborate about it. She stated at that time she told CNA G she needed to be out of that room and discussed it with scheduling and the DON. The UM explained the nurses in conjunction with the CNAs completed the shift assignments daily. She added, in the past, she had received grievances involving CNA G when she was suspended for similar concerns, and they educated her. She explained when a resident requested a staff member not to be assigned to him or her, they switched the room assignment not to make that resident feel uncomfortable. She indicated she was not sure why last week CNA G did not mention to the nurse or to her she had been assigned resident #2 so they could adjust the assignment. She recalled CNA H would switch one room with CNA G in the past. The UM stated when she asked CNA H what happened her response was she did not know but confirmed she had delivered resident #2's breakfast and lunch trays. She indicated resident #2 confirmed he had read the grievance RN E wrote up on his behalf before he signed it. On 2/13/24 at 2:47 PM, the DON stated they initially received a grievance dated 2/05/24 from resident #2, written by his nurse, which he signed. She explained the grievance was discussed on 2/06/24 during the morning meeting. She recalled resident #2 was upset because he told his CNA when she picked up the lunch tray he needed to be changed and the CNA did not return. The DON stated management was not aware he did not want CNA G to take care of him. She stated CNA G worked the swapping of assignment among CNAs and did not inform management. She stated CNA H was not aware she was assigned to resident #2. On 2/15/24 at 5:05 PM, the DON stated the abuse coordinator was the SSD, but she completed the abuse report for resident #2 because she was the only one with access. She explained all grievances were discussed in morning and standdown meetings. She indicated when a grievance was determined to be an abuse or neglect allegation, they reported it to the State within 2 hours if abuse or 24 hours if neglect. The DON stated reporting was not done within 24 hours for resident #2 because there was confusion if care had been provided or not. Later at 7:15 PM, the DON stated she did not recall discussion with the management team to submit an immediate report to AHCA for the allegation of neglect from resident #1. She stated the UM had spoken with resident #1 and he did not express any concerns. In response to a phone call made by the surveyor, on 2/16/24 at 4:50 PM, via telephone interview, the Assistant Administrator stated two allegations of neglect were brought up in morning meeting last Tuesday 2/06/24. She recalled the SSD shared 2 residents complained they did not get ADL care during the 7 AM to 3 PM shift on Monday 2/05/24. She stated the Administrator and the DON were present during the meeting. She indicated the DON told her she was going to submit a State report and asked her to assist with the investigation. She explained she went to the Rehab Unit to look for but was unable to locate Monday's assignment sheet to confirm which CNA was assigned to those residents. She said she informed the DON and Administrator the forms could not be located and asked what else was needed for the investigation. She stated the DON told her she was going to discuss next steps with the Regional Nurse Consultant and the report to the State was not submitted. She recalled by Thursday 2/08/24 she was very disturbed the reports were not yet filed so she emailed the Corporate Team and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105430 If continuation sheet Page 5 of 11 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete included the Administrator and DON noting the noncompliance she was aware of at that time, including the allegation of neglect by the two residents. Review of the facility policy and procedure titled Abuse Policy - FL dated 12/04/23 read, It is the policy of this facility that reports of abuse (mistreatment, neglect or abuse . ) are promptly and thoroughly investigated. The policy revealed all abuse allegations were reported per Federal and State Law. The facility will ensure that all alleged violations involving abuse, neglect, . are reported immediately ., or not later than 24 hours if the events that cause the allegation do not involve abuse and do not in serious bodily injury, to the administrator of the facility and to other officials (including the State Survey Agency and adult protective services .) in accordance with State law through established procedures. If an incident or allegation is considered reportable, the Administrator or designee will make an initial (immediate or within 24 hours) report to the State Agency. Event ID: Facility ID: 105430 If continuation sheet Page 6 of 11 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. 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, Administration failed to effectively oversee and monitor the eligibility status of active employees working with residents in the facility. Residents Affected - Some Findings: 1. Review of employee records revealed Certified Nursing Assistant (CNA) C was hired by the facility on [DATE]. Review of the Agency for Health Care Administration (AHCA) Level 2 Background Screening Result revealed the status was Screening in Process with no Eligibility Determination Date. The employment record included a copy of an AHCA Level 2 Background Screening Result printed on [DATE] which revealed CNA C was eligible as of [DATE] and the Retained Print Expiration Date was [DATE]. Review of the facility's nursing assignment sheet and Keys CNA assignment for Monday, [DATE] revealed CNA C worked the 7 AM to 3 PM shift. On [DATE] at 7:15 PM, the Director of Nursing (DON) stated she noticed fingerprints had expired for CNA C during a facility wide audit conducted on [DATE]. She stated she informed the employee, who was on vacation, to get fingerprints before returning to work. 2. Review of employee records revealed Licensed Practical Nurse (LPN) D, was hired by the facility on [DATE]. Review of AHCA Level 2 Background Screening Result completed on [DATE] revealed a status of Screening in Process with no Eligibility Determinate Date. On [DATE] at 11:34 AM, LPN D was observed working in the Keys Unit and was assigned to care for residents. On [DATE] at 5:25 PM, the Administrator and Director of Nursing (DON) showed a copy of LPN D's AHCA Level 2 Background Screening Result page showing Screening in Process. The DON stated the AHCA system prompted Initiate Resubmission for some employees during their audit. She stated she thought that message meant the expiration was coming up and she initiated the resubmission. The Administrator stated while the screening was in process, the employee was eligible to work. He then presented a copy of AHCA Level 2 Background Screening result printed on [DATE] showing LPN D was eligible as of [DATE] and the Retained Print Expiration Date was [DATE]. He explained they resubmitted because the system prompted them with a message in red. He stated although the status read Screening in Process, Employee D's fingerprints expired on [DATE], therefore, she was eligible to work. 3. Review of employee records revealed LPN A was hired by the facility on [DATE]. Review of the Nursing Homes Federal Reporting revealed the Immediate Report was submitted to AHCA on [DATE] and listed the event occurred on [DATE] at 10:00 AM. The AHCA report was completed by the DON. The Background Information section included the facility was self-reporting from an audit conducted on [DATE] to [DATE] where it discovered LPN A's nursing license status was delinquent. On [DATE] at 3:12 PM, during a telephone interview, the Human Resources (HR) Director stated she had to use the DON's credentials to access AHCA background website as she did not have her own. She explained the DON was the only person in the facility who received emails from the AHCA background (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105430 If continuation sheet Page 7 of 11 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 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 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some unit when alerts and notifications were sent. She shared she received only one email which was forwarded by the DON last September regarding the upcoming expiration of fingerprints for LPN A. She said she had reviewed new employees' background screening, not the existing ones. She explained while reviewing an employee's file for disciplinary action, the DON discovered there were 5 or 6 employees whose fingerprints were expired for months. She recalled in [DATE] the Administrator signed the forms for the HR Director to obtain her own credentials for the facility's background screening website, but it was declined because he was not listed as the Administrator on record for the facility. She added she checked licensed personnel's licenses when onboarding because they had a payroll system that alerted them of professional licenses expiration dates. The HR Director stated she requested assistance to audit the employee files and the Assistant Administrator performed the audits in [DATE]. She stated the Assistant Administrator never mentioned any licenses nor fingerprints had expired. She shared the Assistant Administrator sent a message to their corporate team informing them she noticed LPN A's nursing license expired [DATE] and she had left a note in the employee's file for the HR Director but did not tell her she needed to check urgently. The HR Director stated when she received HR training it did not include license verifications for active employees. She stated she began working as the HR Director the 3rd week of August and the expiration of LPN A's license was on [DATE]. She explained the [NAME] President of HR covered the HR Director role before her. On [DATE] at 12:17 PM, the [NAME] President of HR stated they were responsible for the overall HR Operations for facilities in Florida. She explained she was the HR Director in the facility for a few months until one was hired in mid-August. She stated during that time, she covered two facilities filling the HR Director roles. She recalled she processed payroll, onboarded new hires, processed background checks, and addressed employee relation issues and questions. She stated the DON and former Administrator assisted with some of the HR tasks she was unable to perform because she was covering the two facilities. She said she was on survival mode at that point. She stated she used the former Administrator's credentials to access the AHCA Background Screening website. She explained the authorized registered users with the AHCA Background website received the notifications the system generated before fingerprints expired, and any arrest and status change alerts. She mentioned in a perfect world, that person would get the report, review, and address it. She stated during the time she worked in the facility she did not check fingerprint expiration dates for existing employees. She stated LPN A's expired license was probably missed during a time the payroll system had a glitch. She said the HR Director was not responsible for the license mishap that would have been me. She explained everyone in the facility reported to the Administrator and the role of the regional or corporate team was to offer support. She stated if they feel there is a problem, they come to the Administrator and mention it because the Administrator was ultimately responsible. On [DATE] at 2:47 PM, the DON and Administrator explained during the audit they identified 6 staff members with expired fingerprints and 5 employees with eligible background status but were not included on the facility roster. The DON explained LPN A was one of the six employees with expired fingerprints. She indicated during the audit, she found out LPN A's nursing license status was delinquent. She stated the license renewal due date was [DATE]. She stated she was concerned because LPN A had been working with an inactive license. On [DATE] at 7:15 PM, the DON showed copies of emails she received with notification of fingerprints to expire [DATE] for LPN A. The first email was dated [DATE] with a subject line that read, Clearinghouse BGS (Background Screening) Notification: Background and Retained Prints Expiration Dates. The email read, The screening and retained prints expiration date for the individual(s) listed below are set to expire over the next 60 days from the date of this notification followed by LPN A's name (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105430 If continuation sheet Page 8 of 11 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 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 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and the expiration date [DATE]. The second email dated [DATE] read, The screening and retained prints expiration date for the individual(s) listed below are set to expire over the next 60 days from the date of this notification. Expiring within 21 days followed by LPN A's name and the expiration date [DATE]. On [DATE] at 5:25 PM, the Administrator stated while screening was in progress, the employee was eligible to work. He explained when he started in October, he did not submit a change of Administration application to AHCA and the Administrator of record was inaccurate. He indicated because of this oversight, when he tried to make changes and grant the HR Director access to the background screening it was denied. He stated she was using the DON's access and the expiration alerts, or any notification would have been sent to the DON. The DON recalled she received LPN A's notification of expiration of fingerprints because someone from another facility within the corporation forwarded it to her. The DON and Administrator did not provide an answer as to why they did not know there were staff with expired fingerprints and delinquent license working with residents. The DON stated that was the HR Director's responsibility. On [DATE] at 5:55 PM, the Administrator stated he reviewed the survey history of the facility and performed one on one meetings with department managers to better understand their work and challenges. The Administrator acknowledged he was responsible for the overall oversight of the facility. In a response to a telephone call on [DATE] at 5:00 PM, the Assistant Administrator stated during a telephone conversation on [DATE], the [NAME] President of HR asked the DON if she updated the expiration date for the Background and license in their payroll system for LPN A. She stated the LPN A's nursing license expired on [DATE] and her fingerprints had also expired. She said she heard the Regional Nursing Consultant say if they reported it was going to open a can of worms. She stated there were questions about expiration dates. She stated after the call, the DON told her the [NAME] President of HR was aware of LPN A's fingerprints expiration since [DATE] because she had forwarded the notification to her. She stated she was asked by the Administrator to assist the HR Director to audit the physical HR files starting on [DATE]. She stated she found the physical files had not been updated in a while and she told the HR Director her findings while she was going through the audit. She indicated she told the HR Director there were many items missing when she started the review and there was a lot not found. She stated the Administrator and DON were aware of the situation because when she began auditing the HR files on [DATE] the DON came in the HR Director's office and told her, Oh girl those files are a hot mess, before (name of HR Director) was here I was HR, DON, and Administrator, so I know those files are not complete. The Assistant Administrator stated she told the Administrator about her findings but he said to allow time for the HR Director to get through payroll system to determine if the documents were there. She recalled noting LPN A's license and fingerprint expiration but since she had no computer access, she wrote a note of the checklist and left for the HR Director to check as instructed by the Administrator. She stated she did not believe she mentioned LPN A name specifically to the Administrator or the DON. She stated she should have probably done a bit more to help the HR Director during the audit process. She stated she knew there were regulations on screening and licensing of healthcare professionals for the safety of the residents. She said if she would have thought unlicensed staff were working in the facility, she would have requested access to verify. She said, I completely regret it and take full responsibility for not looking deeper into those files. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105430 If continuation sheet Page 9 of 11 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 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 0839 Employ staff that are licensed, certified, or registered in accordance with state laws. 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 a Licensed Practical Nurse (LPN) with an expired license did not provide care to residents, for 1 out of 5 nurses selected for employee record review, (LPN A). Residents Affected - Few Findings: Review of employee records revealed LPN A was hired by the facility on [DATE]. Review of the Nursing Homes Federal Reporting revealed the Immediate Report was submitted to the Agency for Health Care Administration (AHCA) on [DATE] and listed the event occurred on [DATE] at 10:00 AM. The AHCA report was completed by the Director of Nursing (DON). The Background Information section included the facility had self-reported from an audit conducted on [DATE] to [DATE] where it was discovered LPN A's nursing license status was delinquent. On [DATE] at 8:23 AM, LPN A stated she worked at the facility for two years and was the Unit Manager (UM) for the Palms unit for approximately a year. She explained she had been a nurse for 7 years. She indicated her nursing license was good until [DATE]. She shared she went on maternity leave last May and after she had her new baby everything went off her mind. She stated she returned to work sometime in [DATE] and never made a payment to renew her nursing license which expired in [DATE]. She stated she never heard anything from the facility regarding her license and did not receive notice that her license was inactive. She said, It totally went out of my mind until the DON mentioned they were going to perform an audit on all the licenses. She stated she immediately went online to check her license and saw it was inactive. She recounted she called the Board of Nursing (BON) and found out what she needed to do to make it active again. She stated the next day her nursing license was cleared and active. She acknowledged she administered medications and provided nursing care to residents in the facility from [DATE] to February 2024 without an active license She said, I totally get it is my responsibility, but HR never said anything was wrong with it either. She mentioned in addition to an inactive nursing license, she learned on Wednesday [DATE] her fingerprints were expired. She indicated her address was incorrect with the BON because when she moved at the end of 2022, she did not update it. She stated she did not know she had to update her address with the BON every time she moved. On [DATE] at 3:12 PM, during a telephone interview, the Human Resources (HR) Director stated she had been in the role for less than 6 months and did not have previous HR experience. She indicated she checked licensed personnel's licenses when onboarding new employees. She explained the facility used a payroll system that showed the professional license's expiration dates, and it would alert them when renewal was due. The HR Director stated she requested assistance from the Administrator to audit the employee files. She recalled the Assistant Administrator performed the employee HR files audit in [DATE]. She stated the Assistant Administrator never mentioned any licenses were expired. She recalled when the expired license issue was uncovered, the Assistant Administrator sent a message to their corporate team informing them LPN A's nursing license had expired on [DATE] and had left a note in the employee's file on top of a file cabinet in the HR Director's office. The HR Director stated training did not include going over license verification for active employees. She stated she began working as the HR Director the 3rd week of August and the expiration of LPN A's license was on [DATE]. She explained the [NAME] President of HR covered the HR Director role before her and she learned she was covering two buildings at that time. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105430 If continuation sheet Page 10 of 11 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105430 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 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 0839 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On [DATE] at 12:17 PM, the [NAME] President of HR stated she worked as the HR Director from May to [DATE] because the facility did not have an HR Director at the time. She explained it was the HR Director's responsibility to perform audits of employee files and review professional licenses. She indicated they entered license expiration dates in their payroll system which assisted with tracking. She recalled there was a glitch in the system which showed license compliance in red and they were told to ignore it. She mentioned license verification was relayed in the date entered in the payroll system because they could generate a report and review licenses that would expire within a specific timeframe and get notification via email. She stated noting LPN A's expired license was probably missed during the time of the glitch in their payroll system. She said the HR Director was not responsible for the license mishap, That would have been me. She explained everyone in the facility reported to the Administrator and the role of the regional or corporate team was to offer support. She stated if they feel there is a problem, they come to the Administrator and mention it, because the Administrator was ultimately responsible. She mentioned she did not perform any file audits during the months she was the Interim HR Director. She recalled she learned the facility found LPN A's had been working with an expired nursing license it was stressful to hear about it and very unfortunate. She explained a nurse with an expired license should not be allowed to work as this posed a risk to the residents. She indicated as a nurse LPN A was aware she had to maintain an active nursing license especially as she was a nursing manager. The [NAME] President of HR stated, It was disheartening and definitely stressful. On [DATE] at 2:47 PM, the DON and Administrator explained during an HR audit, LPN A's nursing license status was delinquent. The DON stated LPN A's license expired on [DATE]. She stated she was concerned because LPN A had been working with an inactive license. Later on [DATE] at 5:25 PM, the DON provided 23 dates LPN A was assigned to directly care for residents. The DON and Administrator did not provide an answer as to why they did not know there was staff with a delinquent license working with residents. The DON stated that was the HR Director's responsibility. The following day, on [DATE] at 5:55 PM, the Administrator acknowledged he was responsible for the oversight of the facility. Review of the facility policy and procedure titled Abuse Policy - FL dated [DATE] revealed one of the seven step approaches of the abuse policy was screening. The policy revealed employees were screened prior to working with residents. Screening components included verification of references, certification and verification of license and criminal background check. Review of the Facility assessment dated and reviewed with Quality Assurance Performance Improvement committee on [DATE] listed under Staff training / education and competencies, We ensure our staff are licensed/certified as applicable for their position. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105430 If continuation sheet Page 11 of 11