Health inspection·August 4, 2022

F 0583 Level of Harm - Minimal harm or potential for actual harm they also have signs on the door for precautions. Staff B stated the map is posted in different parts of the building so they can see where COVID-19 is. An observation on 8/2/22 at 2:01 PM revealed the COVID-19 resident map was also posted in the hallways next to room [ROOM NUMBER] and room [ROOM NUMBER]. Residents Affected - Few An interview was conducted with Staff C, Registered Nurse (RN), Unit Manager (UM) on 8/2/22 at 2:36 PM. She indicated the admissions department posts the maps and updates them anytime a resident has COVID-19. She stated, families might want to know were COVID rooms are. Staff C reviewed the photo including the map and Resident #351's room/name tag. She confirmed this does show Resident #351 has COVID-19. When asked about privacy concerns regarding diagnosis being posted, she stated either way, the sign on the door says .oh, droplet precautions, not COVID. She stated it could be a privacy problem and she never thought about that. An interview was conducted with the Nursing Home Administrator (NHA) on 8/2/22 at 2:45 PM. She stated the maps are on the wall to indicate COVID-19 positive residents and step downs. The NHA said they put them up so someone that comes in the building they can know where the COVID positive rooms are. They are also for staff. She reviewed the photograph of the COVID-19 map next to Resident #351's room, indicating his name. She stated the map shows Resident #351 has COVID-19. When asked about this being a privacy concern, she stated they have been doing this all through COVID. The NHA administrator stated someone from the Agency for Healthcare Administration (later corrected to the Department of Health) asked them how they were educating staff on where COVID positive residents were, so they started putting the map up. Regarding having resident names and their COVID diagnosis being displayed she stated, they have precaution signs on the door. She stated she was going to look for documentation showing she was told posting the maps was okay. On 8/3/22 at 9:37 AM the NHA stated they did not have anything in writing regarding posting the maps with COVID-19 diagnoses, it was a verbal discussion with someone from the Department of Health. She stated all maps have now been removed. A review was conducted of two facility provided policies titled Resident [NAME] of Rights and Notice of Privacy Practices. These policies are given to each resident upon admission. The Resident [NAME] or Rights stated, You have the right to personal privacy and confidentiality of your personal and clinical records. The Notice of Privacy Practices stated, We are required by law to maintain the privacy and security of your protected health information. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. The United States Department of Health and Human Services: Your Rights Under HIPAA (Health Insurance Portability and Accountability Act) states the following: -Covered entities must put in place safeguards to protect your health information and ensure they do not use or disclose your health information improperly. -Covered entities must reasonably limit uses and disclosures to the minimum necessary to accomplish their intended purpose. -Covered entities must have procedures in place to limit who can view and access your health information as well as implement training programs for employees about how to protect your health information. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105568 If continuation sheet Page 2 of 16 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 105568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Woods Rehab and Healthcare Center 13719 Dallas Dr Hudson, FL 34667 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 0583 (https://www.hhs.gov/hipaa/for-individuals/guidance-materials-for-consumers/index.html) Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105568 If continuation sheet Page 3 of 16 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 105568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Woods Rehab and Healthcare Center 13719 Dallas Dr Hudson, FL 34667 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility did not ensure air conditioning (A/C) units were maintained in a sanitary manner in 7 rooms (room [ROOM NUMBER], 128,130,219, 217, 216 and 218) out of 19 rooms in the front hall of the facility during four of four days of the survey Findings included: During a facility tour on 08/01/22 from 09:37 a.m. to 10:11 a.m., observations were made of air conditioning (A/C) units with dark moisture lint on the surfaces and filters with debris and dust in resident rooms 126, 128, 130, 216, 217, 218 and 219. The observations of A/C units with dark moisture lint on surfaces and filters with debris and dust were made on 08/02/22 at 11:32 a.m., 08/03/22 10:00 a.m., and 08/04/22 11:20 a.m. A review of a maintenance logbook documentation dated, 7/29/22, 7/22/22 and 7/15/22 showed boxes not checked to indicate cleaning of air filters was conducted in these rooms. On 08/04/22 at 11:00 a.m., an interview was conducted with the Housekeeping Manager. He stated the housekeeping department was responsible for wiping the outside of the unit. He stated the maintenance department was responsible for making sure filters were cleaned. The Housekeeping Manager confirmed any surface dirt should be wiped off during routine room cleaning. The housekeeping manager reviewed A/C units observed with dark moisture and lint on the surfaces and stated the housekeeping department should be cleaning them daily. An interview was conducted on 08/04/22 at 11:41 a.m. with the Director of Maintenance (DOM). The DOM stated the black stuff is moisture and lint mixture and is caused by condensation and dust. The DOM stated he follows a deep cleaning schedule. The DOM stated he takes the covers outside and cleans them yearly. The DOM stated the filters are cleaned in each wing, each week. The DOM stated he was the only one in the maintenance department and tries to get through all the resident rooms. The DOM stated he tries to alternate each wing weekly. The DOM reviewed photographic evidence and said, that needs to be vacuumed. We will get on it. A follow -up interview was conducted with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on 08/04/22 at 12:20 p.m. The NHA stated the Maintenance Director cleans the units on a rotation. The NHA reviewed the evidence and stated the units were cleaned recently and they would be cleaned again today. The DON reviewed the photographic evidence and stated they did not look clean. They stated the units had already started to be cleaned. The NHA stated they did not have a policy on maintenance of A/C units but housekeeping had one on cleaning all surfaces. Review of a housekeeping facility policy titled, Cleaning light covers and vents, revised 9/5/2017, showed under timing and method: Wipe every vent with germicide. Vents in resident's rooms should be cleaned daily as part of the step cleaning method. Vents in hallways, dining rooms etc., should be scheduled for regular cleaning. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105568 If continuation sheet Page 4 of 16 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 105568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Woods Rehab and Healthcare Center 13719 Dallas Dr Hudson, FL 34667 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 0584 If necessary, have maintenance remove covers to clean inside the vents. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105568 If continuation sheet Page 5 of 16 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 105568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Woods Rehab and Healthcare Center 13719 Dallas Dr Hudson, FL 34667 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility did not ensure a dependent resident (#16) was assisted to activities during three of four days of survey out of 41 residents sampled. Residents Affected - Few Findings included: During a facility tour on 08/02/22 at 10:19 a.m., Resident #16 was observed sitting on the edge of his bed. Resident #16 stated he does not participate in activities. Resident #16 stated he would like to but he is just not invited. Resident #16 said, I thought the activities are for residents with insurance. Immediately following this tour, an observation was made of the Director of Activities (DOA) with a group of residents in the dining room playing bingo. A review of an admission record for Resident #16 dated 08/04/22 showed Resident #16 was admitted to the facility on [DATE] with diagnosis to include but not limited to muscle wasting and atrophy, transient cerebral ischemic attack unspecified and difficulty in walking. A review of the Minimum Data Set (MDS) for Resident #16, dated 05/22/22, showed under Section G: Functional Status revealed Resident #16 required extensive assistance for bed mobility and transfers. Resident #16 was dependent on staff for transfers. A review of a care plan for Resident #16, dated 5/5/22, revealed an activities focus area as: resident requires staff assistance with involvement of activities related to, requires physical assistance to and from activities. Interventions included: Discuss with the resident prior level of activity involvement and interests. Encourage resident to participate with activities of choice. The resident needs assistance/escort to and from activity functions. On 08/02/22 at 2:45 p.m., an observation was made of a group of residents attending a live music presentation in the dining room. Resident #16 was not in attendance. An interview was conducted with Resident #16 on 08/02/22 at 02:46 p.m. Resident #16 was observed seated at the same spot all day, on the edge of his bed, facing the door. Resident #16's room was close enough to the dining room to hear the live music. Resident #16 re-stated he thought the activities in the dining room were for some residents with a certain type of insurance. Resident #16 stated he was not invited to attend Bingo this morning, or the live music that was going on in the dining room. On 08/03/22 at 2:15 p.m., an observation was made of residents in the dining room during an ice- cream social event. Resident #16 was not in attendance. A follow -up interview was conducted with Resident #16 on 08/03/22 at 2:19 p.m. Resident #16 stated he had not been asked if he wanted to participate in the ice-cream social. Resident #16 stated he had not been assisted to any activity's events. Resident #16 stated he did not know what activities they had planned or if he could attend. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105568 If continuation sheet Page 6 of 16 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 105568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Woods Rehab and Healthcare Center 13719 Dallas Dr Hudson, FL 34667 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview was conducted on 08/03/22 at 4:05 p.m. with the DOA. The DOA stated she conducts an initial assessment upon admission to identify resident's hobbies, what they like and find out if they need supplies. The DOA stated if residents are dependent on staff, they are assigned 1:1 supports for in room activities or escort to the activity area. The DOA stated they bring the activities to their rooms and invite the residents who want to attend group activities. The DOA stated Resident #16 does not get out of bed that much and she did not know if it's a comfort level. The DOA stated she did not invite Resident #16 to bingo, music, or the ice-cream social. The DOA confirmed Resident #16 had not refused to attend activities and if he was it would be documented. The DOA stated she goes door to door inviting residents to activities every morning. The DOA confirmed she had not invited Resident #16 to any activities. The DOA said, I did not go to that side today. I do not have a good explanation. I do not have anything against him. It's a simple mistake. The DOA stated she was the only one in the department and was not able to get around all the time. The DOA stated she would discuss the concern with the Nursing Home Administrator (NHA), may be the certified nurse's aide (CNAs) can help. The DOA said, I will do better. An interview was conducted with the NHA on 08/03/22 at 3:55 p.m. The NHA stated Resident #16 should be participating in activities if he chooses. The NHA said, He should be invited and escorted. The NHA stated there was no reason why the resident was not assisted to activities. The NHA stated they would educate the staff. A review of resident council meeting minutes dated 5/19/22, 6/17/22 and 7/22/22 showed the council suggests for staff to assist in bringing other residents to planned and on-going activities to increase participation. The review indicated this is an -ongoing concern. On 08/04/22 at 11:49 a.m., a follow-up interview was conducted with Resident #16. Resident #16 stated he enjoyed participating in the activity this morning. Resident #16 said, it was nice to get out and interact with other residents. The resident stated he was looking forward to playing Bingo this afternoon. On 08/04/22 at 12:20 p.m. a follow-up interview was conducted with the NHA and the Director of Nursing (DON). The NHA stated they have spoken to the resident, and he attended activities this morning. The DON stated the CNA's do assist in prompting and assisting residents get ready for activities. The DON stated they will make sure Resident #16 is invited to activities going forward. Review of a facility policy titled, Activities Overview, dated October 2021, showed the activities department will provide activities that include sensitivity and an understanding of each individual resident's needs and requirements including medical, emotional, spiritual, therapeutic, and recreational needs. The activity programs will reflect individual needs and provide / promote the following: Stimulation or solace Physical, cognitive and or emotional health. Enhancement, to the extent practicable, of each resident's physical and mental status. Resident self-respect by providing activities that support self-expression, social and personal responsibility, choice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105568 If continuation sheet Page 7 of 16 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 105568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Woods Rehab and Healthcare Center 13719 Dallas Dr Hudson, FL 34667 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Actual harm Based on record review, observations, and interviews the facility failed to ensure proper nutritional enhancements were provided as ordered for one resident (#56) of three residents sampled for nutrition resulting in a 6.1% wieght loss in 48 days. Residents Affected - Few Findings included: On 8/02/22 at 3:00 P.M., An observation and interview was conducted with Resident #56. The resident stated the menus never change and she does not get what she orders. She stated if she gets food she does not like and the alternate is not good she just does not eat at all. Resident #56 stated she has lost weight. On 8/3/22 at 8:45 A.M.an interview was conducted with Resident #56. The resident stated no one from Dietary has been in to see her and/or talk with her regarding supplements or her weight loss. She asked if there was a way for her to have supplements added to her meal tickets. On 8/03/22 at 10:30 A.M.a review of the medical record revealed the following weights recorded for Resident #56: 06/05/22- 120.2 pounds 07/08/22- 113.1 pounds 07/16/22- 112.3 pounds 07/23/22-112.9 pounds A review of the medical record revealed a Nutritional Evaluation dated 03/21/22, completed by the Facility Registered Dietician (RD). The diet order stated supplements, fortified foods, and snacks were to be added to the resident meal tickets. On 07/12/22 a Nutritional Evaluation was completed by the Facility Registered Dietician and an updated diet order was placed to add magic cup supplements to the resident meal tickets. A review of the residents medical record revealed documentation under tasks for Resident #56 indicating the resident consumed 50% of most meals served, and no information was found regarding the percentage of supplements consumed. On 8/03/22 at 2:00 P.M. an interview was conducted with the RD. He stated if a resident has an order for fortified food, it would be documented and would be listed as part of the diet on the tray ticket. He stated if a resident had an order for a nutrition supplement, that would also print on the tray ticket and be the last food item listed. The RD stated if a resident had weight loss, that would also trigger interventions for supplements to be put into place. He said he would do a nutritional assessment and put the order into the system for supplements. He stated the resident would then be placed on weekly weights so they could monitor if the resident was gaining, losing, or staying the same. The RD stated there is no specific monitoring practice, but these items would be listed on the resident's tray ticket, which then would be addressed by the dining staff during tray line so the resident would receive the appropriate food items and supplements. The RD stated he completed two (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105568 If continuation sheet Page 8 of 16 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 105568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Woods Rehab and Healthcare Center 13719 Dallas Dr Hudson, FL 34667 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 0692 Level of Harm - Actual harm Residents Affected - Few nutritional evaluations for Resident #56, one in March 2022 and the other in July 2022. He stated the diet orders and supplements were placed in the system, but after reviewing the resident's diet history, unfortunately they were never transferred to the resident's tray ticket. The RD stated he could not confirm if the resident was receiving the supplement on her supper tray, since he is not here at evening meals. The RD confirmed Resident #56 had not received any fortified food or the nutritional supplements for the past 4 months. The RD stated he had not met or had any conversation with Resident #56 regarding her supplements or interventions that were in place. The RD stated, apparently we have dropped the ball on this resident and that is unfortunate. On 8/04/22 at 10:45 A.M. an interview with the Director Nursing (DON) was conducted. The DON stated the residents should be interviewed to see if we are meeting their preferences, likes and dislikes. She stated they need to make sure the residents are not receiving foods they do not eat for one reason or another. She stated they would make adjustments for meals for residents to increase portion size, add snacks per day, in-between meals, supplements between meals, adding fortified foods, and higher calorie food items. The DON stated a resident would go on weekly weights and the Inter-Disciplinary Team would follow the resident until a safe Body Mass Index (BMI) and weight was achieved. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105568 If continuation sheet Page 9 of 16 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 105568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Woods Rehab and Healthcare Center 13719 Dallas Dr Hudson, FL 34667 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, interviews and record review, the facility failed to store medications in a safe and secure manner 1) in four medication carts (two A Wing and two C Wing) of four medication carts observed, and 2) for three residents (#16, #63, and #82) of forty one residents sampled. Findings included: 1) A review of the facility provided policy titled 4.1 Storage of Medications, dated 09/18 revealed the following: Policy: Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations to maintain their integrity and to support safe effective drug administration. The medications supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medication. Procedures: 1. The provider pharmacy dispenses medications is containers that meet state and federal labeling requirements, including requirements of good manufacturing practices established by the United States Pharmacopeia (USP). On 08/03/2022 at 2:59 p.m., an observation of the (C Wing) 200 Back Hall medication cart included two (2) loose pills. Staff L, Licensed Practical Nurse (LPN) confirmed the presence of the unsecured blue and white capsule, and one round white tablet. Photographic evidence was obtained. On 08/03/2022 at 03:16 p.m., an observation of medication cart on (C-Wing) 200 Front Hall included one loose tablet in the fourth draw from the top of the medication cart. Staff M, (LPN), confirmed the presence of the unsecured tablets. On 08/03/2022 at 03:32 p.m., an observation of medication cart on (A-Wing) 100 Hall included one loose beige tablet in the second draw, one orange, and one white loose pill in the fourth draw, and in the fifth draw from the top of the medication cart, a large yellow loose pill. Staff N, Registered Nurse (RN) confirmed the presence of the unsecured tablets. On 08/03/2022 at 04:00 p.m., an observation was conducted of medication cart (A-Wing) 100 High Hall. During the observation a loose while tablet was seen in the 4th draw. The fifth draw included 1 large white oval tablet from the top of the medication cart. Staff H (LPN) confirmed the presence of the unsecured medications. On 08/03/2022 at 4:14 p.m., an interview with the Director of Nursing (DON) was conducted. She was informed of all observations made. The DON indicated staff informed her prior to the interview, of unsecured tablets found in the medication carts on both wings. The DON revealed her expectation would be staff checking at a minimum once a week the medication carts for loose pills. She further indicated her unit managers are currently checking the medication carts once a week. 2) On 08/02/22 at 9:42 a.m., a large off-white oval tablet was found on the floor in Resident #16's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105568 If continuation sheet Page 10 of 16 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 105568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Woods Rehab and Healthcare Center 13719 Dallas Dr Hudson, FL 34667 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm room, The tablet was inscribed Carafate. Resident #16 stated he takes the tablet. Resident #16 stated he might have dropped it. Photographic evidence was obtained. A review of Resident #16's physician orders dated 8/4/22 revealed orders for Sucralfate tablet 1 mg, give 1 tablet one time a day for GERD, give before meals. Residents Affected - Some On 08/02/22 at 9:45 a.m., an interview was conducted with Staff L, LPN. Staff L made the observation and said, the resident may have dropped it. It was an accident. Staff L stated the expectation would be to supervise the residents during medication administration. On 08/02/22 at 9:57 a.m. a white, round tablet was observed on the floor in Resident #63's room at the foot of bed. Resident #63 stated she did not know the tablet fell. Photographic evidence was obtained. On 08/02/22 at 10:02 a.m., an interview was conducted with Staff L. Staff L stated the tablet was Plavix. Staff L stated the two residents in the room take Plavix. Stated he did not know how the tablet ended up on the floor by Resident #63's bed. He stated he knew he administered both resident's medications in the morning. On 08/03/22 at 10:04 a.m., a white tablet was observed on Resident #82's blanket. An immediate interview was conducted with Resident #82. Resident #82 stated she probably dropped it. Resident #82 stated she was not sure what the medication was. 08/03/22 at 10:06 a.m., a follow -up interview was conducted with the assigned nurse, Staff H, LPN. Staff H walked into the room and observed Resident #82 pulling her hand from her mouth. Staff H stated the resident had just put the tablet in her mouth. Staff H reviewed the photographic evidence of a white tablet on the resident's blanket. Staff H said, it probably just fell when she was taking her medications. Staff H stated she should have supervised the resident. During a facility tour of Resident #82's room on 08/03/22 at 12:24 p.m., a white round tablet was observed under the resident's bed. A follow -up interview was conducted on 08/03/22 at 12:44 p.m. with the DON. The DON made the observation and stated she did not know what the tablet was but would review the resident's record. The DON followed up after review and stated the tablet is propafenone HCI tablet 225 MG Give 1 tablet by mouth every 12 hours for A-FIB (Atrial Fibrillation). The DON confirmed it was an important medication and the resident should not have missed it. A review of Resident #82's physician orders dated 8/4/22 showed the resident was prescribed Propafenone HCI tablet 225 mg, give 1 tablet by mouth every 12 hours for A-FIB. On 08/03/22 at 12:47 p.m. an interview was conducted with the DON and NHA. The DON stated residents should be supervised during medications administration. The DON said, the nurse should stay with the resident during medication administration. The DON stated four incidents or lose tablets in resident's rooms are one too many. The NHA stated they will educate the nursing staff. The DON confirmed the nurses should stay with the residents and provide supervision. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105568 If continuation sheet Page 11 of 16 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 105568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Woods Rehab and Healthcare Center 13719 Dallas Dr Hudson, FL 34667 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 08/02/2022 at 12:15 p.m. an observation was conducted of Resident #67's room from the hall. Resident #67's room door was observed to be open, with an Isolation Precaution box of Personal Protective Equipment (PPE) hanging over the top of the door. The signage on the door revealed Contact Isolation and read PPE required every time you enter room-Mask, Gown and Gloves. (PHOTOGRAPHIC EVIDENCE OBTAINED.) During the observation Staff R, Certified Nursing Assistant, (C NA) was observed entering Resident #67's room with a lunch tray. Staff R, (C NA) placed the tray on the resident's bedside table, removed the cover, and re-arranged items on the table. She then moved the privacy curtain to speak to Resident #67's roommate. Staff R, (C NA) left the room and used the hand sanitizer, on the wall outside the resident's room. An immediate interview was conducted with Staff R, (C NA), when she exited Resident #67's room. Staff R, (C NA) who confirmed she did not put on a gown, and gloves prior to entering Resident #67's room. She stated I do not have to put a gown on, I am just dropping off a tray, and I don't have to put PPE on because I did not do resident care, only if you do resident care, you put a gown on. I am supposed to use the hand sanitizer on the wall and that is the policy of the facility. Residents Affected - Few A record review for Resident #67 revealed Physician Order dated 07/20/2022 for Contact Isolation Precautions every shift for Vancomycin-Resistant Enterococcus (VRE), in the urine. During an interview conducted on 08/04.2022 at 09:10 a.m. with Staff O, Infection Preventionist (IP), she was informed of an observation of Resident #67's room and Staff R, (C NA). Staff O, (IP) revealed if the staff member is not providing resident care in a Contact Isolation room and stated, We'll no she does not have to wear a gown. An interview was conducted with the Director of Nursing (DON), and the IP on 08/04/2022 at 10:12 a.m. During the interview the DON was informed of observations made of Staff R, (C NA) in Resident #67's room. The DON revealed all staff who enter an isolation precaution room must follow the sign's directions. She further indicated if the sign says to put a gown on, or gloves then you must put it on. The DON stated She (Staff R, (C NA) should have put on a gown and gloves. At 11:49 a.m., the DON provided a copy of an in-service training related to Contact Isolation Precautions that was given to Staff R, (C NA) by the IP. According to the Centers for Disease Control and Prevention (CDC) VRE in Healthcare Settings | HAI | CDC VRE Can spread from one person to another through contact with contaminated surfaces or equipment or through person to person spread, often via contaminated hands. Based on observations, interviews, and policy reviews the facility did not ensure 1) proper infection control practices were followed for three Covid-19 positive residents (#344, #351, and #352) regarding personal protective equipment and 2) proper infection control practices were followed for one contact isolation resident (#67) regarding personal protective equipment out of forty one sampled residents. 1) An observation was made on 8/1/22 at 1:01 PM of Staff D, Licensed Practical Nurse (LPN), (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105568 If continuation sheet Page 12 of 16 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 105568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Woods Rehab and Healthcare Center 13719 Dallas Dr Hudson, FL 34667 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few entering Resident #344's room with no goggles in place, only regular eyeglasses. Signage on the door indicated droplet precautions, stating everyone must clean hands when entering/exiting room, wear N95 mask, wear eye protection, and gown and glove at the door. A review of admission records indicated Resident #344 was admitted on [DATE] with diagnoses including pneumonia due to SARS-associated Coronavirus. Lab results indicated the resident tested positive for COVID-19 on 7/17/22. A review of orders indicated an active order for COVID: Droplet precautions, dated 7/20/22. On 8/2/22 at 8:23 AM Staff D, LPN was observed exiting Resident #352's room with a protective gown on. The LPN then entered Resident #344's room with the same gown on. She had no goggles in place, only eyeglasses. On 8/2/22 at 12:58 PM. Staff D, LPN was observed exciting Resident #352's room with a protective gown and gloves on. Staff D kept the same gown and gloves on, picked up the lunch tray for Resident #351 and entered the room to deliver the tray. A review of admission records indicated Resident #352 was admitted on [DATE] with diagnoses including COVID-19. Lab result indicated the resident test positive for COVID-19 on 7/26/22. A review or orders revealed an order for COVID: droplet precautions, dated 8/2/22. A review of Resident #352's care plan indicated Infection: The resident has actual infection: has signs/symptoms or diagnosis of COVID-19. Interventions included, educate staff, resident, family and visitors of COVID-19 signs and symptoms and precautions. The care plan was dated 8/2/22. A review of admission records indicated Resident #351 was admitted on [DATE] with diagnoses including COVID-19. Lab result indicated the resident test positive for COVID-19 on 7/26/22. The resident's orders revealed an order for COVID: droplet precautions, dated 8/2/22. A review of Resident #351's care plan indicated Infection: The resident has actual infection: has signs/symptoms or diagnosis of COVID-19. Interventions included droplet precautions, follow COVID-19 screening/precautions and educate staff, resident, family and visitors of COVID-19 signs and symptoms and precautions. The care plan was dated 8/2/22. On 8/2/22 at 2:10 PM an interview was conducted with the Regional Nurse. She stated when going in COVID positive rooms everyone should wear an N95, goggles/face shield, and gloves every time. She stated when the staff member is finished in the COVID area, they should exit the building through the exit door near the rooms, walk to the front of the building, get a new mask at the front door and reenter the facility. The Nursing Home Administrator (NHA) and Director of Nursing (DON) joined the interview. The NHA stated the process for COVID rooms is donning PPE at the bins outside the door, then go in the room. When leaving, the person should doff PPE before opening the door to the room, then step out into the clean area (hallway.) Then the staff member exits the building if they are finished in the COVID area, they get a new mask and come in the front door of the facility. The DON stated eyeglasses do not count as goggles. She said staff have face shields to wear. She stated goggles are ok, but the staff member must clean them when they exit the building before returning in the front door. The NHA specified the face shields are one time use only. An interview was conducted on 8/2/22 at 2:36 PM with the facility's Infection Preventionist (IP). She stated eyeglasses do not meet the requirements of goggles for precautions. She stated the hall is a clean area and no gown or gloves should be worn in the hall after leaving a precaution room. She also confirmed gowns and gloves should be changed between each resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105568 If continuation sheet Page 13 of 16 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 105568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Woods Rehab and Healthcare Center 13719 Dallas Dr Hudson, FL 34667 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 8/3/22 at 9:37 AM the NHA stated she came in early that morning and reviewed the video of the exit door nearest the COVID positive rooms. She confirmed she saw Staff D come out of a COVID positive room into the hallway with her gown still on with no goggles or face shield. An interview was conducted with Staff D on 8/3/22 at 2:10 PM. She stated she didn't take the gown off in the hallways because someone from the Department of Health told her she could go from COVID room to COVID room without changing gowns because they have the same infection. She stated she had a face shield hanging inside the resident room and she puts it on once she enters. She said she just leaves it there and reuses it. She confirmed she has been trained on PPE use and infection control. She stated she knows she messed up and will be doing it right from now on. On 8/4/22 the IP provided documentation showing the began a hand hygiene competency checklist, as well as donning and doffing PPE competencies for staff on 8/3/22 and in-service on precautions on 8/2/22. A facility policy titled COVID-19 Guidance, dated October 2020, was reviewed. Under the heading Communication/Education the policy stated, routine staff meeting to include contractors to provide education about COVID-19 and measure the facility is taking, including signs and symptoms to report: -Practice proper hand washing hygiene. Soap and water should be used preferentially if hands are visibly dirty. All employees should clean their hands before and after interaction with residents and their environment with an alcohol-based hand sanitizer that contains at least 60-95% alcohol or wash their hands with soap and water for at least 20 seconds. -Don the appropriate PPE as required. Face mask must always be worn during your entire shift. Failure to wear a face mask or don the appropriate PPE could lead to termination after the employee has signed education. -Educate staff on special unit set up and current PPE guidance based on availability and CDC guidelines to prevent the spread of the coronavirus disease. A facility policy titled Isolation Precautions-Categories of Transmission-Based Infection, dated October 2020 was reviewed. The policy stated, Transmission-based precautions shall be used when caring for residents who are documented or suspected to have communicable diseases or infections that can be transmitted to others. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105568 If continuation sheet Page 14 of 16 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 105568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Woods Rehab and Healthcare Center 13719 Dallas Dr Hudson, FL 34667 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observations, staff interview and facility record review, the facility failed to ensure one of one walk in freezers were operating appropriately during two of four days observed (08/01/2022 and 8/4/2022). It was determined the freezer door would not latch closed in order to keep warm air from getting in, and as a result, there was ice build up inside the freezer compartment. Residents Affected - Some Findings included: On 8/1/2022 at 9:45 a.m. the kitchen was toured with the Dietary Manager. During the tour, it was noted the kitchen had a walk in refrigerator and within the walk in refrigerator was the walk in freezer. Once the walk in refrigerator was approached, the door was opened and the inside temperature revealed 38 degrees F., per the inside analog thermometer. Further observations and while inside the walk in refrigerator, there was a large metal door that led into the walk in freezer. The door appeared slightly ajar and the door handle was not latched all the way. The door, when attempting to open, was slightly stuck. Upon pulling open the door with force, the entire inside of the door frame and the entire length of the door was observed with heavy ice build up. Further, there was large ice patches and ice growth on the face of the inside door. The ice build up along the door frame and on the door seal prevented the freezer door to appropriately latching closed. The Dietary Manager confirmed the door was not shutting closed properly and she could not say how long the ice had been built up. The size of the ice build up revealed the ice had been preventing the door from closing properly for a long period of time. Photographic evidence was taken. Also, the inside walk in freezer temperature read approximately 27 degrees F. - 30 degrees F., per review of the inside analog thermometer. The Dietary Manager confirmed she did not have a current work order out to the Maintenance Director but would do so today (8/1/2022). When walking out from the walk in freezer and then out from the walk in refrigerator, the Maintenance Director was observed in the general area. The Dietary Manager told him of the ice build up and he said he would take care of it and did not have a response as to why the ice was building up on the inside of the freezer door and door seal. On 8/4/2022 at 8:55 a.m. a.m. a kitchen tour with the dietary manager was conducted. When the walk in freezer door was approached, the door did not appear closed correctly. The door could be opened by pulling on the side of the door, rather than unlatching the door handle. The door should be clamped closed from the door handle assembly; and at this time it was not. It was determined the inside door seal that surrounds the door, was so thick, that the weight of the door could not shut completely and properly. The Dietary Manager confirmed the door did not shut completely and the door handle did not latch unless pressing on the door hard. She confirmed the weight of the door should close completely and with the door handle latching appropriately. She did confirm the Maintenance Director did remove all the ice build up surrounding the inner door seal, the door itself from inside, and parts of the motor fan housing on Monday 8/1/2022, after first observed from the State surveyor. The door was attempted to pull all the way open and letting the door self close. However, the door did not latch completely, leaving air from the refrigerator, which was at 39 degrees F., able to flow into the walk in freezer compartment. On 8/4/2022 at 12:25 p.m. an interview with the Maintenance Director revealed the Dietary Manager made him aware on 8/1/2022 of ice build up on the inside of the freezer door to include the door seal, and the inside face of the door. He revealed he cleaned the ice build up and believed the door operated appropriately. The Maintenance Director said he was made aware today on 8/4/2022 the door was not shutting properly. He revealed he went into the walk in refrigerator to look at the door and he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105568 If continuation sheet Page 15 of 16 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 105568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Woods Rehab and Healthcare Center 13719 Dallas Dr Hudson, FL 34667 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 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some said he had to make an adjustment to the door latch so the door would close properly. He also indicated he believed the door seal was appropriate for the door and it did not impede the door from closing. The Maintenance Director was also made aware the door is to close on its own weight and latch on its own and while looking at door closing, the latch would rub up against a portion of the metal shelving that was positioned just to the side of the door. When the latch rubbed against the shelving pole, the door would then slow and the weight of the door would not be able to latch. He indicated he would look at that and try to move the metal shelving to a point where the door would self close. He confirmed he did not have any work orders for the door or latch prior to State visit on 8/1/2022. Interview with the Nursing Home Administrator on 8/4/2022 revealed the facility did not have a specific policy and procedure with relation to walk in freezer door maintenance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105568 If continuation sheet Page 16 of 16