Inspection·June 2, 2023

F 0623 stated the nurse should put a copy of the completed form in the front of the resident's chart. Level of Harm - Minimal harm or potential for actual harm On 6/01/23 at 11:50 AM, the facility was asked to provide documentation of the written transfer and discharge notifications for resident #82 and #99. Residents Affected - Few On 6/01/23 at 4:17 PM, the Nursing Home Administrator (NHA) stated they were unable to provide documentation that resident #82 or #99 nor their representative signed and received the Notification of Transfer or Discharge form. On 6/01/23 at 4:35 PM, the Director of Nursing (DON) stated she was not sure what the process was for the Notification of Transfer or Discharge forms at the facility. She explained the nurses sent them in the packet with the resident to the hospital. She did not know if a copy was made or if there was any documentation done to indicate the resident or their representative had been notified of the requirements on the form. On 6/02/23 at 11:10 AM, the East Wing UM stated she now recalled they stopped sending the transfer forms, a while ago. She explained management of the facility kept changing hands and the process kept changing, so they hadn't been done since at least last year. The East Wing UM stated the purpose of the form was to notify the resident or family of why the resident needed to be transferred and where they were being transferred to. On 6/02/23 the Social Service Director stated he was told by the last DON that nursing department would handle the transfer forms and the nurse managers were responsible to send a copy to the resident's representative. He explained prior to that, the Social Services department was responsible to help track the notifications. He acknowledged the point of the notifications were for the resident or representative to be able to dispute any facility-initiated transfers if desired. On 6/02/23 at 12:36 PM, the DON stated her expectation was nurses should complete the Notification of Transfer or Discharge form, make a copy of it, send a copy with the resident, and place the facility's copy in the resident's chart to go into the medical record. Review of the Transfer or Discharge Notice policy with revision date of December 2016, revealed the resident and/or representative would be notified in writing of the reason, the effective date, the location, the right to appeal, contact information for the Long-Term Care Ombudsman, and other related agencies. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105518 If continuation sheet Page 2 of 15 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 105518 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winter Garden Rehabilitation and Nursing Center 12751 W Colonial Drive Winter Garden, FL 34787 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a comprehensive individualized care plan with interventions to address administration of Continuous Positive Airway Pressure (CPAP) for 1 of 3 residents reviewed for respiratory care of a total of 58 residents, (#90). Findings: On 5/30/23 at 1:45 PM, resident #90 was observed in her room. She was alert and oriented to person, place, and time. She had a CPAP device observed on her bedside table. Resident #90 said she recently became very sick with Corona Virus Disease 2019 (COVID 19) which made her weak and unable to get out of bed. Prior to the infection she was able to walk up and down the halls with her walker. She explained she could not use her CPAP when she became sick. The resident indicated concerns that CPAP equipment had not been cleaned, the mask did not fit properly, and the humidifier reservoir water had not been changed since she had COVID 19. Resident #90 was admitted to the facility from the community on 3/1/22 with diagnoses that included obstructive sleep apnea, heart failure, age related debility, and recently positive for COVID 19 on 5/18/23. Review of the resident's medical record showed a physician order dated 3/1/22 currently in effect for, CPAP with setting of 9 CMH2O (centimeters of water) pressure with mask humidification apply at HS [bedtime] and removed in AM every evening shift, fill humidifier every night and clean mask after use. Further review of the physician orders showed that transmission-based precautions were in effect from 5/19/23 to 5/29/23 due to resident testing positive for COVID 19. An invoice dated 11/14/2022 showed the special equipment (CPAP) was delivered to the facility for the resident #90 and included a small full-face mask. The Minimum Data Set (MDS) assessment dated [DATE] showed resident 90's Brief Interview for Mental Status (BIMS) was 14, indicating she was cognitively intact. CPAP therapy was included as special treatment while a resident in the facility. Review of resident #90's care plans revealed there was no specific care plan for CPAP therapy related to her diagnosis of obstructive sleep apnea. On 6/2/23 at 11:03 AM, Licensed Practical Nurse (LPN) MDS Coordinator said resident #90's respiratory care plan was initiated on 3/1/22 for congestive heart failure and hypertension. The MDS nurse admitted she did not realize the resident had diagnosis of obstructive sleep apnea or was using CPAP until yesterday. She acknowledged that since the resident had an order for CPAP dated 3/1/22, it should have been added to the comprehensive care plan at that time. The MDS nurse explained that if the CPAP intervention was added to the comprehensive care plan, the interventions specific to resident #90's needs and goals could have been customized. She verified the comprehensive care plan regarding sleep apnea had been overlooked for more than one year. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105518 If continuation sheet Page 3 of 15 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 105518 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winter Garden Rehabilitation and Nursing Center 12751 W Colonial Drive Winter Garden, FL 34787 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 6/2/23 at 2:36 PM, Registered Nurse (RN) MDS coordinator said she had been at the facility for a few years and did not recall any discussion at the Interdisciplinary Team (IDT) meetings regarding resident #90's diagnosis of obstructive sleep apnea nor intervention of CPAP. She acknowledges there was an active order for CPAP dated 3/1/22 for resident #90. She said the pulmonary physician notes dated 6/2/22 and 9/15/22 included active diagnosis of obstructive sleep apnea. She explained that although the resident had respiratory care plan in effect for difficulty breathing, congestive heart failure and hypertension, there was no mention of obstructive sleep apnea with CPAP. She acknowledged the plan of care did not have individualized goals including application of CPAP, cleaning or follow up with pulmonary physician. Review of the facility policy for Care Plans, Comprehensive Person-Centered revised December 2016 read, A comprehensive, person center care plan that include measurable objectives and timetable to meet resident's physical, psychosocial and functional needs is developed and implement for each resident. The Interdisciplinary Team [IDT], in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive person-centered care plan for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment .The comprehensive, person-centered care plan will .Describe services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial wellbeing .Identify the professional services that are responsible for each element of care .Reflect currently recognized standards of practice . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105518 If continuation sheet Page 4 of 15 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 105518 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winter Garden Rehabilitation and Nursing Center 12751 W Colonial Drive Winter Garden, FL 34787 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 provide care and services consistent with professional standards of practice pertaining to continuous positive airway pressure (CPAP) for 1 of 3 residents (#90) reviewed for respiratory care, and failed to ensure oxygen concentrator was maintained in a clean manner for 2 of 3 residents (#28, #79) reviewed for respiratory care and failed to provide oxygen rate per physician order for 1 of 3 residents reviewed for respiratory care (#28) of a total of 58 residents. Residents Affected - Few Findings: 1. Resident #90 was admitted to the facility on [DATE] with diagnoses of obstructive sleep apnea, heart failure, neuropathy, diabetes, osteoarthritis left shoulder, age related debility, and recently positive for COVID 19 (Coronavirus Disease 2019) on 5/18/23. A Pulmonary consultation note dated 9/15/22 read, This [AGE] year-old female. History of Present Illness .Telemedicine follow-up for obstructive sleep apnea. Patient's obstructive sleep apnea was diagnosed 8 years ago .Patient is compliant with CPAP and using it every night .Her CPAP machine is very old, and she needs a new CPAP machine .5/10/22 30-day compliance reported was reviewed with patient. Patient is very compliant with therapy-using and benefiting . An invoice dated 11/14/2022 showed the special equipment (CPAP) was delivered to the facility for the resident #90 and included a small full-face mask. The Minimum Data Set (MDS) assessment dated [DATE] showed resident 90's Brief Interview for Mental Status (BIMS) was 14, indicating she was cognitively intact. CPAP therapy was included as special treatment. Review of the physician orders showed transmission-based precautions were in effect from 5/19-5/29/23 due to resident testing positive for COVID 19. On 5/30/23 at 1:45 PM, resident #90 was observed in her room. She was alert and oriented to person, place, and time. She had a CPAP device on her bedside table with the reservoir half full of water. Resident #90 said she was recently very sick with COVID 19 which made her weak and unable to get out of bed. Prior to the infection she was able to walk up and down the halls with her walker. She explained when she had COVID 19, she could not use her CPAP. The resident indicated concerns that CPAP equipment had not been cleaned. She indicated the mask did not fit properly, and the humidifier reservoir water had not been changed since having COVID infection. She said she used CPAP at home prior to coming to the facility and cleaned the equipment at home with soap/vinegar and water. Review of resident #90's medical record showed a physician order dated 3/1/22 currently in effect for, CPAP with setting of 9 CMH2O (centimeters of water) pressure with mask humidification, apply at HS [bedtime] and removed in AM every evening shift, fill humidifier every night and clean mask after use. Review of the Treatment Administration Record (TAR) record from 5/22/23-5/31/23 showed Licensed Practical Nurses (LPN) B, C, D, F and H documented providing ordered treatments and cleaning equipment. Review of the nurses' notes and TAR showed no documentation of resident refusal for treatments. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105518 If continuation sheet Page 5 of 15 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 105518 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winter Garden Rehabilitation and Nursing Center 12751 W Colonial Drive Winter Garden, FL 34787 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observations conducted from 5/30/23 to 6/2/23 revealed CPAP equipment at the bedside with humidifier reservoir half full of water. Interviews with the resident revealed she had not received CPAP treatments and was reluctant to use CPAP equipment as it had not been cleaned since her recent COVID 19 infection. On 6/1/23 at 9:37 AM, the resident was observed in bed. The CPAP machine was on the bedside table and remained the same as yesterday with the water reservoir half full. The resident stated she did not use CPAP last night. The resident added, the nurse did not clean CPAP or offer to assist with treatment either. The resident denied refusal of treatment. On 6/1/23 at 1:33 PM, LPN A said resident #90 had recent COVID 19 infection which caused her decline. She stated the resident could go to the bathroom by herself prior to getting ill and now, she needs help with bathing and activities of daily living (ADLs). On 6/1/23 at 1:35 PM, the East Unit Manager (UM) verified resident #90 just came off isolation precautions this week and had not started physical therapy (PT) as she was still too weak. On 6/1/23 at 4:37 PM, LPN C verified she worked the 3 PM to 11 PM shifts from 5/29 to 5/31/23 and was assigned to resident #90's care. She said resident #90 refused her CPAP treatment last night. Review of the medical record showed LPN C provided treatment and did not document refusal. LPN C indicated she cleaned the CPAP equipment with diaper wipes, but had not added any water to the reservoir for humidification. She acknowledged she had not changed the CPAP mask since the resident came off isolation precautions. She did not know if the equipment had been changed or if the mask fitted properly. On 6/1/23 at 4:44 PM, the Director of Nursing (DON) said LPN B who cared for the resident from 5/23 to 5/25/23 on the 3 PM to 11 PM shift documented providing CPAP treatment and cleaning of mask. The DON stated, LPN B was currently out of the country and not available for an interview. The DON validated that none of the nurses documented refusal of treatments. On 6/1/23 at 5:13 PM, LPN G was assigned to resident #90's care on 3 PM to 11 PM shift on 5/19/23 and today. LPN G stated, she had not cleaned the CPAP mask or equipment as it did not need to be done daily. LPN G explained she used alcohol pads to clean the face mask and washed the canister with sterile water. LPN G said she did not know if the equipment at bedside was clean or changed since resident came off isolation precautions. LPN G did not know how often mask and tubing needed to be changed. On 6/1/23 at 5:47 PM, the East UM said resident #90 had orders for CPAP treatment nightly and she had not been assessed by Respiratory Therapist (RT) to ensure proper mask fitting. The UM explained the assigned nurse was responsible for cleaning the mask which her son brought to the facility not too long ago. The UM said she thought CPAP equipment was cleaned with plain water but was not sure. The UM reviewed the medical record and verified the nurses had not documented any refusal of treatment nor had they reported this to her. On 6/1/23 at 5:59 PM, LPN F who was assigned to the resident on the 3 PM to 11 PM shift on 5/27/23 stated, I normally do nothing with resident #90's CPAP as she is self-sufficient. LPN F verified she had not added any water to the CPAP humidifier reservoir and said she cleaned the equipment weekly by wiping the exterior surfaces with sanitizing wipes. She said she did not know how to clean or empty the reservoir. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105518 If continuation sheet Page 6 of 15 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 105518 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winter Garden Rehabilitation and Nursing Center 12751 W Colonial Drive Winter Garden, FL 34787 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 6/2/23 at 9:54 AM, resident #90's son said he had not visited his mother since she was on isolation precautions for COVID. He verbalized, his mom was on CPAP at home for years prior to coming to the facility. He indicated he brought new masks every few months until the facility changed her CPAP machine. He was informed by the facility that they would now provide the masks since they were leasing the CPAP machine. He explained the facility staff kept telling him that they would take care of her CPAP needs and getting her fitted for proper mask. He said he still provided distilled water for the CPAP humidifier reservoir as the facility would not provide it. On 6/2/23 at 10:23 AM, the DON said resident #90 was on isolation for 10 days. She verified the CPAP equipment at the bedside was leased and she did not know if anyone ever checked to ensure proper fitting of full-face mask. The DON noted they did not replace the mask or tubing unless, they break. The DON did not know what the standard of practice was to change the mask or tubing. She was not aware how often the reservoir should be cleaned and only had physician orders for nurses to clean the mask daily with soap and water. The DON verbalized, she expected the bedside nurse to clean all equipment and provide new distilled water in the reservoir when the resident came off isolation precautions on 5/29/23. The DON clarified it was the facility's responsibility to provide all needed equipment and distilled water for CPAP treatments. On 6/2/23 at 11:40 AM the resident informed the East UM she had not received her CPAP treatments. The resident added someone said they cleaned the equipment while she was asleep but the reservoir was never changed and was still half full of water. The facility policy and procedure for CPAP/BiPAP Support revised March 2015 read, Purpose 1. To provide the spontaneously breathing resident with continuous positive airway pressure .2. To improve arterial oxygenation .in resident with respiratory insufficiency, obstructive sleep apnea, 3. To promote resident comfort and safety .General Guidelines for Cleaning .Specific cleaning instructions are obtained from manufacturer .Machine cleaning: Wipe with warm, soapy water and rinse at least once a weak and as needed. 4. Humidifier .a. use clean, distilled water only in the humidifier chamber. B. Clean humidifier weekly and air dry. c. To disinfect, place vinegar-water solution .6. Masks, nasal pillows, and tubing: Clean daily by wiping mask with mild soap and warm water . Based on general wear and tear, we suggest that you use the following as a guideline to replace your CPAP parts: Every month; Mask cushions and/or nasal pillows, CPAP machine filters. Every 3 months; Mask frame (not including the headgear), CPAP tubing. Information obtained on 6/9/23 https://www.resmed.com (manufacture of CPAP device observed at bedside). 2. Review of resident #28's medical record revealed she was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), pulmonary edema, and pleural effusion. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented she was receiving oxygen. Review of resident #28's plan of care for alteration in respiratory status, difficulty breathing related to her COPD and to provide oxygen (O2) as ordered. Review of the physician's orders dated 02/07/22 noted to encourage and assist resident to use O2 at 1 Liter (L) per minute via nasal cannula (nc) continuously every shift for shortness of breath. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105518 If continuation sheet Page 7 of 15 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 105518 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winter Garden Rehabilitation and Nursing Center 12751 W Colonial Drive Winter Garden, FL 34787 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 05/31/23 at 9:41 AM, 11:40 AM and 4:03 PM, resident #28's oxygen concentrator was set to deliver 3L of O2 per minute via nc. The vents on the resident's concentrator were covered with gray dust. On 06/01/23 at 9:28 AM, the resident's O2 concentrator was set at 2L per minute via nc and the gray dust remained on the concentrator's vents. On 06/01/23 at 10:29 AM, Licensed Practical Nurse (LPN) I stated resident #28 had a physician order for O2 at 1 L per minute. At 10:30 AM, LPN I observed resident #28's oxygen concentrator and stated the concentrator was set at 1.5 L per minute and she confirmed the vents were dirty. 3. Review of resident #79's medical record revealed she was admitted to the facility on [DATE] with diagnoses of COPD, anemia and was legally blind. Review of the Quarterly MDS assessment dated [DATE] showed she received oxygen therapy. Review of resident #79's plan of care for respiratory status with difficulty breathing directed nursing staff to provide oxygen, check oxygen saturations and to monitor for signs and symptoms of respirator distress. Review of the physician's orders dated 12/09/21 documented O2 at 2L per minute via nc and to check concentrator setting to read 2L every shift. Observations conducted on 05/30/23 at 2:22 PM, 05/31/23 at 9:36 AM and 4:03 PM, and on 06/01/23 at 9:50 AM revealed resident #79 received O2 at 2L per minute. The oxygen concentrator's external was completely covered with a layer of gray dust which was able to be peeled off of the filter. 06/01/23 at 10:30 AM, LPN I confirmed the oxygen concentrator's external filter was completely covered with layer of gray dust. LPN I explained the oxygen concentrator takes in room air through a filter to deliver clean oxygen to the resident. If the filter is blocked the air can not get through to deliver the correct amount of O2 to the resident. She stated, I have never cleaned the oxygen concentrator filters. On 06/01/23 at 10:36 AM, the Central Supply staff member explained the blue oxygen concentrators were rented and the black concentrators were facility owned. I am not sure who is responsible for cleaning the oxygen concentrators. It may be the maintenance staff. On 06/01/23 at 10:49 AM, an interview with the Maintenance Director (by telephone) revealed he was not responsible for the cleaning of the concentrator filters. Review of the facility's Oxygen Administration Policy, revised October 2010, read, The Purpose of the procedure is to provide guidelines for safe oxygen administration. Preparation 1. Review the physician's order . for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident . Steps in the Procedure . 9. Check the mask, tank, humidifying jar, ect., to be sure they are in good working order . 10. Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated . Review of the Facility Assessment documented the facility is competent to provide oxygen therapy services to residents with diagnosis of the respiratory system which included COPD, Pneumonia, Asthma, Chronic Lung Disease, and Respiratory Failure. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105518 If continuation sheet Page 8 of 15 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 105518 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winter Garden Rehabilitation and Nursing Center 12751 W Colonial Drive Winter Garden, FL 34787 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure nursing staff received the necessary training for care of residents on continuous positive airway pressure (CPAP) therapy for 1 of 3 residents reviewed for respiratory care of a total of 58 residents, (#90). Findings: Resident #90 was admitted to the facility from the community on 3/1/22 with diagnoses that included obstructive sleep apnea, heart failure, neuropathy, diabetes, osteoarthritis left shoulder, age related debility, and recently positive for Corona Virus Disease 2019 (COVID 19) on 5/18/23. A Pulmonary consultation note dated 9/15/22 read, This [AGE] year-old female. History of Present Illness .Telemedicine follow-up for obstructive sleep apnea. Patient's obstructive sleep apnea was diagnosed 8 years ago .Patient is compliant with CPAP and using it every night .Her CPAP machine is very old, and she needs a new CPAP machine .5/10/22 30-day compliance reported was reviewed with patient. Patient is very compliant with therapy-using and benefiting . An invoice dated 11/14/2022 showed the special equipment (CPAP) was delivered to the facility for resident #90 and included a small full-face mask. The Minimum Data Set (MDS) assessment dated [DATE] showed resident 90's Brief Interview for Mental Status (BIMS) was 14, indicating she was cognitively intact. CPAP therapy was included as special treatment while a resident in the facility. Review of the physician orders showed that transmission-based precautions were in effect from 5/19-5/29/23 due to resident testing positive for COVID 19. On 5/30/23 at 1:45 PM, resident #90 was observed in her room. She was alert and oriented to person, place, and time. She had a CPAP device observed on her bedside table with the reservoir half full of water. Resident #90 said she recently got very sick with COVID 19 which made her weak and unable to get out of bed. Prior to the infection she was able to walk up and down the halls with her walker. When she was infected with COVID 19, she could not use her CPAP. The resident indicated concerns that CPAP had not been cleaned, and the mask did not fit properly. She stated the water in the reservoir had not been changed since she had COVID 19 and remained half full. She said she used CPAP at home prior to coming to the facility and cleaned the equipment at home with soap/vinegar and water. Review of resident #90's medical record showed a physician order dated 3/1/22 currently in effect for, CPAP with setting of 9 CMH2O pressure with mask humidification, apply at HS [bedtime] and removed in AM, every evening shift fill humidifier every night and clean mask after use. Review of the Treatment Administration Record (TAR) record from 5/22-5/31/23 showed Licensed Practical Nurses (LPN) B, C, D, F and H documented providing ordered treatments and cleaning equipment. Review of the nurses' notes and TAR showed no documentation of resident refusal for treatments. Observations conducted from 5/30/23-6/2/23 revealed resident #90's CPAP equipment at the bedside. The reservoir was half full of water. Interviews with resident #90 revealed she had not received CPAP (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105518 If continuation sheet Page 9 of 15 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 105518 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winter Garden Rehabilitation and Nursing Center 12751 W Colonial Drive Winter Garden, FL 34787 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few treatments and was reluctant to use equipment as it had not been cleaned since prior to having COVID 19 infection. On 6/1/23 at 9:37 AM, resident #90 was observed in bed and the CPAP on bedside table was observed same as yesterday with water reservoir ½ full of water. The resident said she did not use CPAP last night. She noted the nurse did not clean the CPAP equipment or offer to assist with treatment. She noted she did not refuse treatment. On 6/1/23 at 4:37 PM, Licensed Practical Nurse (LPN) C verified she worked the 3 PM to 11 PM shifts from 5/29 to 5/31/23 and was assigned to resident #90's care. She said resident #90 refused her CPAP treatment last night. Review of the medical record showed LPN C provided treatment and did not document refusal. LPN C added that she cleaned the CPAP equipment with diaper wipes, and she did not add any water to the reservoir for humidification. LPN C verbalized she did not realize she could go to the DON/ADON to ask questions regarding care/equipment she was not familiar with. The nurse verified she did not change CPAP mask since resident came off isolation and did not know if the equipment had been changed out or if the mask fitted properly. On 6/1/23 at 4:44 PM, the Director of Nurses (DON) validated that none of the nurses documented refusal of treatments. On 6/1/23 at 5:13 PM, LPN G who was assigned to resident #90's care on 3 PM to 11 PM shift on 5/19/23 and today stated she did not clean CPAP mask or equipment as it did not need to be done daily. LPN G explained she used alcohol pads to clean the face mask and washed the canister with sterile water. LPN G denied having any training regarding use/care of CPAP equipment and did not know if the equipment at bedside was clean or changed since the resident came off isolation for COVID 19. LPN G did not know how often mask and tubing needed to be changed. On 6/1/23 at 5:47 PM, the East Unit Manager (UM) said resident #90 had orders for CPAP treatment nightly and the assigned nurse was responsible for cleaning the mask. The UM explained she thought CPAP equipment was cleaned with plain water. The UM denied having any training regarding use and care of CPAP equipment. On 6/1/23 at 5:59 PM, LPN F who was assigned to the resident on the 3 PM to 11 PM shift on 5/27/23 stated, I normally do not do anything with the resident's CPAP as she is self-sufficient. LPN F verified she had not added any water to the CPAP humidifier reservoir. She noted she cleaned the equipment weekly by wiping down the exterior surfaces with sanitizing wipes and did not know how to clean or empty the reservoir. LPN F denied having any training or competency test regarding use or care of CPAP devices. On 6/2/23 at 9:54 AM, interview with resident #90's son revealed he had not visited his mother since she was on isolation for COVID 19 infection. He verbalized, his mom was on CPAP at home for years prior to coming to the facility. He explained he used to bring her a new mask every couple of months until the facility changed her machine. He was informed by the facility that they would now provide the equipment since the machine was leased by the facility. He stated the facility staff repeatedly told him they would take care of her CPAP needs and getting her fitted for a proper mask. He noted he still provided the distilled water for the CPAP humidifier reservoir and was told the facility was not able to provide it. On 6/2/23 at 10:23 AM, the Director of Nursing (DON) said resident #90 had COVID 19 positive test (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105518 If continuation sheet Page 10 of 15 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 105518 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winter Garden Rehabilitation and Nursing Center 12751 W Colonial Drive Winter Garden, FL 34787 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few on 5/18/23 and was placed on isolation precautions starting 5/19/23 for 10 days. The DON explained changing of CPAP equipment and noted, we do not replace mask or tubing unless they break. The DON was not aware of the standards of practice or manufacturer's recommendations for how often to change the CPAP mask or tubing and did not know how often the reservoir should be cleaned. The DON verified the facility only had orders for nurses to clean the mask daily with soap and water. The DON indicated she did not know if CPAP training was provided to newly hired nurses or if any of the nurses caring for resident #90 ever had CPAP training/competency test. On 6/2/23 at 11:20 AM, resident #90 said she had never refused CPAP treatments and prior to COVID 19, she was able to put mask on by herself. She said she was now too weak to do the treatments by herself. The CPAP equipment was noted same as prior observations on 5/30 to 6/1/23. The CPAP reservoir remained half full of water. The resident stated she did not get her treatment again last night and did not know if the staff ever cleaned the equipment. On 6/2/23 at 12:09 PM, the Assistant Director of Nursing (ADON) verified she was the facility's staff educator and had not done any training with nurses for CPAP equipment. She said the nurses should clean the mask daily with soap and water. The ADON explained resident #90's device needed to be taken apart and cleaned monthly and as needed with soap and water. The ADON clarified that when resident #90 came off isolation precautions, the nurse should have taken the CPAP equipment apart including emptying old water from reservoir and then added distilled water. The ADON explained nurses should have clarified questions they had with CPAP with her when the resident's isolation precautions were discontinued. The ADON conveyed respiratory equipment could harbor bacteria in the tubing, mask, and reservoir. She indicated nurses should not be cleaning equipment with sanitizing or alcohol wipes. On 6/2/23 at 2:01 PM, the ADON verified upon review of the CPAP manufacturer's recommendation the device needed to taken apart and cleaned weekly with warm soapy water and rinsed with tap water. She reported that in general orientation for new nurses, they did not review CPAP equipment and LPN's B, C, D, F, and H who had recently cared for resident #90 had not done any CPAP training competency. The facility policy and procedure for CPAP/BiPAP Support revised March 2015 read, General Guidelines for Cleaning .Specific cleaning instructions are obtained from manufacturer .Machine cleaning: Wipe with warm, soapy water and rinse at least once a weak and as needed. 4. Humidifier .a. use clean, distilled water only in the humidifier chamber. B. Clean humidifier weekly and air dry. c. To disinfect, place vinegar-water solution .6. Masks, nasal pillows, and tubing: Clean daily by wiping mask with mild soap and warm water . Based on general wear and tear, we suggest that you use the following as a guideline to replace your CPAP parts: Every month; Mask cushions and/or nasal pillows, CPAP machine filters. Every 3 months; Mask frame (not including the headgear), CPAP tubing. Information obtained on 6/9/23 https://www.resmed.com (manufacture of CPAP device observed at bedside). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105518 If continuation sheet Page 11 of 15 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 105518 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winter Garden Rehabilitation and Nursing Center 12751 W Colonial Drive Winter Garden, FL 34787 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 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to present up-to-date staffing hours for residents and visitors in a complete and accurate format. Residents Affected - Some Findings: On 5/30/23 at 9:55 AM, observations revealed an incomplete daily staffing projection form to the left of the receptionist desk located on the wall across from the staffing office. The form showed no data for hours for Registered Nurses (RN) on the 7 AM to 3 PM (day shift), Licensed Practical Nurses (LPN) or Certified Nursing Assistants (CNA's) in the columns for 11 PM to 7 AM (night shift), 7 AM to 3 PM (day shift) or 3 PM to 11 PM (evening shift). On 5/30/23 at 3:30 PM, observations revealed no hours entered on the posted daily staffing projection form. During review of the daily staffing posting with the Labor/Staffing Coordinator, she explained she had not posted the hours and no one told her they were to be posted. On 5/31/23 at 1:39 PM, review of the 18 months of various daily staffing projection forms with the Labor/Staffing Coordinator noted staffing form dated 5/1/23 with no hours for RNs on the 7 AM to 3 PM shift. LPNs or CNAs in the columns for 11 PM to 7 AM night shift, 7 AM to 3 PM day shift or 3 PM to 11 PM evening shift or 11 PM to 7 AM night shift. The form dated 4/16/23 showed no hours posted in the columns for LPNs or CNAs for the night shift, or evening shift. The form dated 1/6/23 showed no hours in the columns for RNs on the day shift, LPNs or CNAs for the night shift, day shift or evening shift. The form dated 11/4/22 revealed no documentation of actual hours in the columns for RNs on the day shift, LPNs or CNAs for the night shift, day shift or evening shift. She confirmed there were no hours documented on the above forms. On 5/31/23 at 5:57 PM, the Executive Director stated there was no specific policy regarding posting of staff hours on the staffing sheet. She stated, we put down the number of staff hours for nurses and CNAs working. On 6/01/23 at 10:27 AM, the Labor/Staffing Coordinator stated she was never told to put hours on the staffing sheet. She had worked at the facility for about 20 years and reported to the DON (Director of Nursing), ADON (Assistant Director of Nursing) and the Administrator. On 6/01/23 at 12:18 PM, the DON stated she was not aware that hours needed to be on the posted staffing form. She stated just found out yesterday (5/31/23) or the day before (5/30/23), but can't remember the exact day. On 6/01/23 at 4:26 PM, the Executive Director stated the staffing coordinator indicated she was following the previous education regarding completing the posting forms (Staffing projection forms). She stated we check the date, and posting to make sure it is posted on the board daily. She stated she was accustomed to having the hours on the form, but was unsure if the ADON or the DON knew that the hours were to be posted on the form. She stated she will check to see who was responsible to verify the hours were posted. On 6/01/23 at 5:39 PM, the Executive Director provided a copy of the signed job description for the Labor/Staffing Coordinator and said the DON was responsible for checking that the posted staffing projection forms were correctly completed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105518 If continuation sheet Page 12 of 15 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 105518 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winter Garden Rehabilitation and Nursing Center 12751 W Colonial Drive Winter Garden, FL 34787 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 0732 Review of the Labor/Staffing Coordinator job description dated 1/11/23 showed RESPONSIBILITIES: Establishes staffing patterns and schedules for nurses and nursing assistants. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105518 If continuation sheet Page 13 of 15 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 105518 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winter Garden Rehabilitation and Nursing Center 12751 W Colonial Drive Winter Garden, FL 34787 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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 behavior monitoring was initiated and provided for 1 of 5 residents reviewed for Unnecessary Medication Review out of a total sample of 58 residents, (#434). Residents Affected - Few Findings: Review of resident #434's medical record revealed he was admitted to the facility on [DATE] with diagnoses including Cerebral Vascular Accident (CVA), Anxiety Disorder, Depression and other specified disorders of the brain. Review of the physician's orders dated 05/29/23 documented Trazodone 100 milligrams (mg) orally (po) at hours sleep for major depression, Escitalopram 20 mg po daily for depression, and Buspirone 10 mg po three times a day for anxiety. Review of resident #434's plan of care dated 05/30/23 documented antipsychotic medication use with interventions to monitor/document/report as needed any adverse reactions of antipsychotic medications: unsteady gait, tardive dyskinesia, extrapyramidal side effects (EPS) shuffling gait, ridged muscles, shaking, frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps, nausea, vomiting, behavior symptoms not usual to the person. Uses anti-anxiety medications with interventions to monitor/document/report any adverse reactions to anti-anxiety therapy: drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgement, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision, mania, hostility, rage, aggressive or impulsive behavior, and hallucinations. Review of the 05/01/23 to 05/31/23 and 06/01/23 to 06/30/23 Medication Administration Record (MAR) revealed no behavior monitoring listed on the MAR. It was not until 06/02/23 (4 days after admission) that the behavior monitoring was added to the MAR. On 06/01/23 at 3:17 PM, the Director of Nursing (DON) reviewed resident #434's 05/29/23 physician's orders, care plan and the Medication Administration Records (MAR). The DON stated the required monitoring for the resident's antianxiety, antipsychotic and antidepressant medications was not entered onto his MAR. She explained the nurse had to select the batch button when entering these types of medications in order for the behavior monitoring to be entered on the MAR. Once entered, the nurses were required to complete the behavior monitoring documentation on every shift. She stated, Since the behavior monitoring was not initiated at the time of his admission the nurses were not monitoring or documenting any behaviors related to his medication use. Review of the facility's Behavioral Assessment, Intervention and Monitoring Policy, revised March 2019, read, Policy Statement 1. The facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. 2. Behavioral symptoms will be identified using the facility-approved behavioral screening tools and the comprehensive assessment . Assessment . 3. The nursing staff will identify, document, and inform the physician about specific details regarding changes in an individual's mental status, behavior, and cognition, including: a. Onset, duration, intensity and frequency of behavioral symptoms . Management . 10. When (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105518 If continuation sheet Page 14 of 15 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 105518 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winter Garden Rehabilitation and Nursing Center 12751 W Colonial Drive Winter Garden, FL 34787 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 0757 Level of Harm - Minimal harm or potential for actual harm medications are prescribed for behavioral symptoms, documentation will include: . h. Monitoring for efficacy and adverse consequences . Review of the Facility Assessment, revised May 2, 2023 revealed the facility is competent and able to manage medication-related services related to anxiety and depression. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105518 If continuation sheet Page 15 of 15