Inspection·March 12, 2021

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility did not monitor specific behaviors for one resident (#84) and did not monitor the side effects of psychotropic medications for one resident (#115) out of five residents sampled for unnecessary medications. Findings included: 1. The pharmacy policy titled, Psychotropic Medication Use, that the facility provided, revised 11/28/16, indicated the policy sets forth procedures relating to psychotropic medication use. The procedure portion of the policy indicated: 1. Facility should comply with the Psychopharmacological Dosage Guidelines created by the Centers for Medicare and Medicaid Services (CMS), the State Operations Manual, and all other Applicable Law relating to the use of psychopharmacological medications including gradual dose reductions. The procedure identified the following: - 4. Psychotropic medications to treat behaviors will be used appropriately to address specific underlying medical or psychiatric causes of behavioral symptoms.; - 7. All medications used to treat behaviors must have a clinical indication and be used in the lowest possible dose to achieve the desired therapeutic effect. All medications used to treat behaviors should be monitored for: efficacy, risks, benefits, and harm or adverse consequences. - 12. Facility staff should monitor the resident's behavior pursuant to Facility policy using a behavioral monitoring chart or a behavioral assessment record for residents receiving psychotropic medication for organic mental syndrome with agitated or psychotic behavior(s). Facility staff should monitor behavioral triggers, episodes, and symptoms. Facility staff should document the number and/or intensity of symptoms, and the resident's response to staff interventions. A review of the admission Record revealed that Resident #84 was admitted on [DATE]. The admission Record included diagnoses of unspecified anxiety disorder, unspecified dementia without behavioral disturbance, and unspecified single episode major depressive disorder. The resident's Minimum Data Set (MDS) identified that she scored a 7 out of 15 on a Brief Interview of Mental Status (BIMS) assessment indicative of severe cognitive impairment. A review of Resident #84's physician orders for March 2021 indicated that the resident was being administered the following psychotropic medications: - Cymbalta (Duloxetine HCl) Capsule Delayed Release Particles - Give 40 milligrams (mg) by mouth two times a day for depression. The order started on 9/29/20. - Seroquel (Quetiapine Fumarate) tablet - Give 12.5 mg by mouth one time a day for mood disorders. The order started on 9/29/20. The Order Summary Report for March 2021 instructed the staff to monitor the side effects of the anti-depressant medication, Duloxetine, and the anti-psychotic medication, Seroquel. The report indicated staff were to monitor every shift for depression and to document if side effects were present and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105792 If continuation sheet Page 2 of 18 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 105792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Winter Haven 1510 Cypress Gardens Blvd Winter Haven, FL 33884 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few write a progress note if side effects were not present, to start on 9/26/18. The report identified that staff were to monitor every shift, related to the administration of Seroquel for dementia with behaviors and to document if side effects were present and write a progress note if side effects were not present, to start on 12/18/20. A review of the electronic Medication Administration Record (MAR) and the Treatment Administration Record (TAR) for March 2021 did not include monitoring of the number of behavioral episodes, effectiveness of the intervention, or whether non-pharmaceutical interventions were attempted. During an interview at 10:59 a.m. on 3/11/21 the Director of Nursing (DON) stated that staff do document episodes of behaviors and monitor behaviors, however the monitoring is not in the computer, like the side effects. Staff B, Licensed Practical Nurse (LPN) stated on 3/11/21 at 11:43 a.m., that behaviors are documented in the electronic record under a behavior note and the documentation was done by exception. She reported that staff do inform psychological providers of any behaviors or if new behaviors are exhibited. On 3/11/21 at 2:10 p.m., when asked about the paper Behavior Monitoring Forms (BMF), Staff B stated, Oh I didn't know. When asked where the February (2021) BMFs were, Staff B stated she thought the DON had them. Staff B reported that Resident #84 cries one minute and was happy the next. A review of the Behavior Monitoring Form for Resident #84 indicated that staff were to monitor every shift for the behavior code 12 for the anti-depressant medication, Cymbal. The included behavior code legend indicated code 12 was for depressed withdrawn. The BMF indicated staff were to monitor the behavior code 22 for the antipsychotic, Seroquel. The legend identified that the code 22 was for mood changes. The BMF indicated that staff were to document the number of episodes, interventions, and outcome. The legend included non-pharmacological interventions numbered 1-12 for specific interventions and 13-15 for other, which interventions could be personalized. The outcome codes indicated staff were to document: I=improved, S=same, and W=worse. The Psychological Medication Management Follow-up, dated 3/3/21, indicated the chief complaint was confusion and Resident #84 had diagnoses of moderate recurrent major depressive disorder, Alzheimer's disease with late onset, and mood disorder due to known physiological condition with mixed features. The history of present illness indicated the symptom was changes in mood and got upset when talking about family as she does not remember daughter visiting or bringing her things. The past medical/psychiatric detail indicated the resident had a history (hx) of aggressive behavior towards a peer and hx of delusions that no one likes her. The psychological assessment identified the resident doing well with current meds. No recent aggression reported. Staff report no overt hallucinations (used to talk to someone when alone in the room). The target symptoms for medication was noted as behavioral disturbances and changes in mood. The care plan for Resident #84 identified the following: - A focus initiated 9/30/20 indicated Resident #84 had the potential to be verbally aggressive(cursing, hitting) related to (r/t) poor impulse control. A goal of the focus, initiated on 9/30/20, was that the resident would verbalize understanding of need to control verbally abusive behavior through the review date. The interventions associated with the focus included staff were to assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, and pain etc. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105792 If continuation sheet Page 3 of 18 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 105792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Winter Haven 1510 Cypress Gardens Blvd Winter Haven, FL 33884 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 0758 Level of Harm - Minimal harm or potential for actual harm - A focus initiated 2/1/19 indicated the resident had a behavior problem (keeping abundant amount of personal belongings in her room and unbagged for easy access per resident wishes). The goal identified that the resident would not experience behaviors that are harmful to self and others through next review date. The goal was initiated on 2/1/19, revised on 3/5/21, with a target date of 5/4/21. The interventions initiated on 2/1/19, were to observe for behavior episodes and attempt to determine underlying cause. Residents Affected - Few - A focus indicated the resident had an alteration in behavior/mood as evident by hoarding. - A focus indicated the resident had a potential to be verbally aggressive (cursing, hitting) r/t poor impulse control and instructed staff to document observed behavior and attempted interventions. On 3/12/21 at 9:56 a.m., Staff B, LPN stated, when asked if Resident #84 became physically aggressive, She has. The staff member stated the resident does hoard crackers in her room and has a drawer of little things that she puts in little cups, and when family brings in candy the resident separated the pieces into little cups. On 3/11/21 the DON was asked for the February 2021 BMF for Resident #84's psychotropic medications. When asked, on 3/12/21 at 11:16 a.m., for a copy of the resident's February BMF, the DON stated that on 2/25/21 she discovered that the BMFs were not in the computer so she printed them (BMF) out and gave them to staff to start documenting behaviors. A review of Resident #84's BMF did not include the resident's reported behaviors of aggression and/or hoarding. During an interview on 3/12/21 at 12:06 p.m., the DON stated the facility printed a paper (BMF) and staff documented behaviors on a flowsheet and side effects in the computer. She stated she would expect the BMF to have a little more specific behaviors and staff to monitor for aggression. 2. A review of Resident #115's medical record revealed that Resident #115 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, altered mental status, and major depressive disorder. A review of Resident #115's care plan revealed a problem, revised on 03/11/2021, that Resident #115 used antidepressant medications related to depression. Interventions included to administer antidepressant medications as ordered, observe for side effects and effectiveness every shift, and observe/report as needed any adverse reactions to antidepressant therapy. Resident #115's care plan also revealed a problem, revised on 03/11/2021, that Resident #115 used psychotropic medications related to disease process. Interventions included to administer psychotropic medications as ordered, observe for side effects and effectiveness every shift, and observe/report as needed any adverse reactions to psychotropic medications. A review of Resident #115's Minimum Data Set (MDS) Assessment revealed, under Section C - Cognitive Patterns, a BIMS score of 01, which indicated severe cognitive impact. The MDS assessment also revealed, under Section N - Medications, that Resident #115 received antipsychotic medications and antidepressant medications 7 days out of the 7 day assessment period. A review of Resident #115's physician orders for March 2021 revealed the following orders: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105792 If continuation sheet Page 4 of 18 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 105792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Winter Haven 1510 Cypress Gardens Blvd Winter Haven, FL 33884 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 0758 Level of Harm - Minimal harm or potential for actual harm - Divalproex Sodium 250 milligrams (mg) by mouth two times daily for psychosis with behavior, dated 02/16/2021. - Risperidone 0.5 mg by mouth three times daily for Alzheimer's with behavioral disturbances, dated 03/03/2021. Residents Affected - Few - Sertraline Hydrochloride 100 mg by mouth one time daily for depression, dated 03/03/2021. A review of Resident #115's physician orders did not reveal an order for side effect monitoring related to psychotropic medication use. An interview was conducted on 03/11/2021 at 4:28 p.m. with Staff A, Registered Nurse (RN). Staff A, RN stated that side effect monitoring for psychotropic medications were documented in the electronic charting system and all residents that take psychotropic medications should have side effect monitoring documented every shift. Staff A, RN was not able to locate side effect monitoring in the electronic charting system for Resident #115. Staff A, RN stated that behavioral monitoring for psychotropic medications was completed on a paper form, but addressed that the paper form did not include monitoring for side effects. An interview was conducted on 03/11/2021 at 4:37 p.m. with the facility's Assistant Director of Nursing (ADON). The ADON stated that side effect monitoring should be documented in the electronic charting system every shift for residents that were taking psychotropic medications. The ADON was not able to find any documentation of side effect monitoring for Resident #115. An interview was conducted on 03/12/2021 at 11:56 a.m. with the facility's Director of Nursing (DON). The DON stated that side effect monitoring for residents that used psychotropic medications was documented every shift in the electronic documentation system. The DON also stated that if a resident was receiving a psychotropic medication, an order for side effect monitoring should be in the electronic charting system. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105792 If continuation sheet Page 5 of 18 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 105792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Winter Haven 1510 Cypress Gardens Blvd Winter Haven, FL 33884 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to ensure that the medication error rate was less than 5.00%. Twenty-eight medication administration opportunities were observed, and four errors were identified for three residents (#3, #44, and #37) of five residents observed. These errors constituted a 14.29% medication error rate. Residents Affected - Few Findings included: 1. On 3/10/21 at 4:08 p.m., an observation of medication administration with Staff A, Registered Nurse (RN) was conducted with Resident #3. Staff A was observed administering the following medications: - Novolog 100 unit/milliliter (u/mL) Flex Pen - 8 units subcutaneously per a blood glucose level of 347. - Hydralazine 50 milligram (mg) orally - Fish Oil 500 mg - 2 capsules - Levemir Insulin pen - 28 units subcutaneously The observation revealed that Staff A, RN dialed the Novolog Flex Pen to 2 units and informed Staff E, Licensed Practical Nurse (LPN), who was orientating, that to prime the pen, dial it to 2 units and wait a minute then turn the dial to the number of units. As Staff A was instructing Staff E, she dialed the insulin to 2 units held in the pen parallel to the floor during her instruction, then dialed the pen to 8 units. When asked how she primed the pen, she stated she had been taught to turn the dial to 2, wait a minute then turn it to the amount to be given. The LPN entered Resident #3's room then injected 8 units of Novolog insulin via Flex Pen into the upper right arm of the resident. She returned to the medication cart and removed a Levemir insulin pen from the medication cart. She placed a needle on the Levemir insulin pen, then dialed the pen to 28 indicative of 28 units. Staff A re-entered the resident's room, observed the resident take the oral medications, and then she injected 28 units of Levemir in the upper posterior right arm. At 4:32 p.m., Staff A stated she had primed the Levemir pen, however the observation did not reveal her dialing to 2 units and waiting a minute per her description of priming the insulin pen. When asked how turning the knob of the pen to 2 units primed the pen, she stated by doing that it was supposed to expel the air from the pen. The manufacturer's Quick Guide for each of the NovoLog Flex Pen and the Levemir FlexTouch pen instructed users as follows: - Prime your pen - Turn the dose selector to select 2 units. Press and hold the dose button. Make sure a drop appears. - Select your dose - Turn the dose selector to select the number of units you need to inject. The pharmaceutical literature included instructions on how to prepare the Novolog Flex Pen: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105792 If continuation sheet Page 6 of 18 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 105792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Winter Haven 1510 Cypress Gardens Blvd Winter Haven, FL 33884 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few - Giving the air shot before each injection. Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: - E. Turn the dose selector to select 2 units. - F. Hold your NovoLog Flex Pen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. - G. Keep the needle pointing upwards, press the push-button all the way in. The dose selector returns to 0. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than 6 times. If you do not see a drop of insulin after 6 times, do not use the NovoLog Flex Pen and contact Novo Nordisk. This information was obtained at https://www.novomedlink.com/content/dam/novonordisk/novomedlink/resources/generaldocuments/NovoLog%20FlexPen% The pharmaceutical literature included the following instructions on how to prepare the Levemir FlexTouch insulin pen: - Priming your Levemir FlexTouch Pen: - Step 7: Turn the dose selector to select 2 units. - Step 8: Hold the Pen with the needle pointing up. Tap the top of the pen gently a few times to let any air bubbles rise to the top. - Step 9: Hold the Pen with the needle pointing up. Press and hold in the dose button until the dose counter shows 0. The 0 must line up with the dose pointer. A drop of insulin should be seen at the needle tip. If you do not see a drop of insulin, repeat steps 7 to 9, no more than 6 times. If you still do not see a drop insulin, change the needle, and repeat steps 7 to 9. https://www.novomedlink.com/content/dam/novonordisk/novomedlink/resources/generaldocuments/LevemirIFU.pdf According to the American Diabetes Association, Trends in Insulin Pen Priming, 2018 July, indicated that Priming insulin pens is recommended to remove air from needles to ensure full dose administration. The information was accessed at https://diabetes.diabetesjournals.org/content/67/Supplement_1/83-LB. During an interview at 4:50 p.m. on 3/10/21, the Director of Nursing (DON) was asked how to prime an insulin pen. She described the procedure in priming an insulin pen as dialing it to 2 units, push the insulin out (using dose button) to see a drop (of insulin) and then users were to dial the dose selector to the number of units to be administered. When the observation of Staff A priming of the insulin pens was shared, the DON confirmed the insulin pen had not been primed correctly. The DON was asked for a policy and procedure for administering insulin via a pen. 2. On 3/10/21 at 4:38 p.m., an observation of medication administration with Staff F, Licensed Practical Nurse (LPN) was conducted with Resident #44. Staff F was observed administering the following medications: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105792 If continuation sheet Page 7 of 18 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 105792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Winter Haven 1510 Cypress Gardens Blvd Winter Haven, FL 33884 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 0759 - Calcium Carbonate 500 mg chewable tablet Level of Harm - Minimal harm or potential for actual harm - Ferrous Sulfate 325 mg tablet - Senna S 50-8.6 mg tablet Residents Affected - Few - Vitamin D3 1000 international unit (iu) capsule A review of Resident #44's physician orders indicated the following medications and dosages were to be administered: - Senna 8.6 mg tablet - Give 1 tablet by mouth at bedtime for constipation. Hold for loose stools. - Vitamin D tablet - Give 2000 iu by mouth one time a day for Vitamin D deficiency. 3. On 3/11/21 at 9:00 a.m., an observation of medication administration was conducted with Staff C, LPN, with Resident #37. Staff C was observed administering the following medications: - 2 Divalproex Delayed Release (DR) 125 mg sprinkles - Nifedipine Extended Release (ER) 90 mg tablet - Furosemide 40 mg tablet - Sertraline HCl 100 mg tablet - Lovastatin 20 mg daily - Creon DR capsule 12000 units, take with food/snack. - Calcium + D 600/200 mg tablet - Simethicone tab 125 mg - Acidophilus 1 billion capsule A review of Resident #37's physician orders indicated the following medication was to be administered with the noted instructions: - Creon Capsule DR 12000 unit, one capsule by mouth three times a day for [NAME] Syndrome. Take with food or snacks. An observation of Resident #37 at 9:14 a.m. was completed after the staff member administered the medication. Resident #37 was observed lying in bed, the over-the-bed table in front of the resident did not hold a meal tray or any snacks. When asked how breakfast was, he stated Great. An observation of the hallway outside of the resident room did not indicate a meal cart. On 3/12/21 at 12:29 p.m., the DON stated she had started education on the priming on the insulin pens and she stated she would have to review the Vitamin orders. When asked how long before or after a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105792 If continuation sheet Page 8 of 18 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 105792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Winter Haven 1510 Cypress Gardens Blvd Winter Haven, FL 33884 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few meal should Creon be administered, she stated she would have to look it up. The physician order was read to her and she stated she wondered who put the order into the computer. The DON reported that Resident #37 snacked all day long and had a drawer of snacks. The Consultant Pharmacist stated, on 3/11/21 at 1:47 p.m., that Creon should be given as close to a meal as possible. On 3/12/21 at 11:55 a.m. the Certified Dietary Manager (CDM) reviewed the times of the kitchen tray line. He stated the listed times are the times that the meal cart leaves the kitchen and should only take five (5) minutes to get to the hall. The review of the 200-hall tray line times indicated both of the halls meal carts would have arrived to the hallway between 6:30 and 6:40 a.m., two (2) hours 20-30 minutes prior to the resident receiving the medication Creon. The policy titled, Administration of Medications, revised 5/6/20, indicated all medications are administered safely and appropriately per physician order to address residents; diagnoses and signs and symptoms. A physician order that includes dosage, route, frequency, duration, and other required considerations including the purpose, diagnosis, or indication of use is required for administration of medication. The policy indicated Insulin - all formulations and strengths as a high-alert medication. Per the policy the facility identified the definition of a medication error was the observed or identified preparation or administration of medications or biologicals which is not in accordance with: 1. The prescriber's order. 2. Manufacturer's specifications (not recommendations) regarding the preparation and administration of the medication or biological; or 3. Accepted professional standards and principles which apply to professionals providing services. Accepted professional standards and principles include the various practice regulations in each state, and current commonly accepted health standards established by national organizations, boards, and councils. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105792 If continuation sheet Page 9 of 18 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 105792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Winter Haven 1510 Cypress Gardens Blvd Winter Haven, FL 33884 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to maintain drugs and biologicals used in the facility in accordance with currently accepted professional principles by not ensuring: 1. one treatment cart (Oasis Suites) was locked while unattended, 2. one comfort kit was discarded timely for a deceased resident in one medication room (Oasis Suites), 3. eye drops with an expiration date was dated when opened on one medication cart (Golden Hall), 4. insulin pens were dated when opened and refrigerated when unopened, and ProSource Plus undated in two medication carts (Oasis Suites Hall and Cypress Hall), and a Victoza pen was stored in the original pharmacy packaging in one medication cart (Oasis Hall) of a total of five treatment carts, seven medication carts and five medication rooms. Findings included: 1. On [DATE] at 11:55 a.m., a treatment cart was observed unlocked and unattended next to the nursing station on the 400-hall, Oasis Suites. Staff B, Licensed Practical Nurse (LPN) was on the resident hallway and Staff E, LPN, was standing at the medication cart parked on the opposite side and across from the nursing station. The first and second drawer of the cart contained prescribed topically ointments, the third drawer contained multiple boxed tubes of Zinc Oxide, and other drawers contained wound care supplies. At 11:57 a.m. on [DATE], Staff B, LPN arrived at the treatment cart and confirmed that the treatment cart was unlocked, unattended, and that residents could access inside the cart. (Photographic Evidence Obtained) 2. On [DATE] at 12:03 p.m. a review of the Oasis Suites medication room was conducted with Staff B. In an unsealed cardboard box, on the bottom shelf of the refrigerator, the following medications were observed inside: - 15 milliliters (mL) of Morphine Sulfate Oral Solution 100 milligram/5 milliliter (mg/mL); - A bottle containing 10 tablets of 0.5 mg Lorazepam (Ativan); - 2 Biscolax suppositories; - 4 650 mg Acetaminophen suppositories. A sticker on the box indicated [DATE] checked [initials]. The Ativan bottle was prescribed to Resident #137. Staff B stated she did not know the box was in the refrigerator. This box was identified as a hospice comfort kit. The admission Record for Resident #137 indicated the resident was initially re-admitted to the facility on [DATE]. A progress note, dated [DATE], identified Resident #137 passed away at 7:00 p.m. on [DATE] and Hospice was notified at that time. 3. On [DATE] at 12:37 p.m., a review was conducted with Staff C, LPN of the Golden Hall medication cart. An opened bottle of Latanprost eye drops, prescribed to Resident #87, was discovered without (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105792 If continuation sheet Page 10 of 18 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 105792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Winter Haven 1510 Cypress Gardens Blvd Winter Haven, FL 33884 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few an open date. The pharmacy sticker instructed staff to keep the bottle refrigerated until opened and discard 42 days after opening. The staff member confirmed the bottle of Latanprost was opened. 4. A review of the Cypress Hall medication cart, on [DATE] at 12:44 p.m., was conducted with Staff G, LPN. An opened 30 mL bottle of ProSource Plus, a collagen and whey protein formula, was observed without an open date. The label on the bottle instructed users to discard three months after opening. Also observed in the Cypress Hall cart was an opened Novolog FlexPen without a documented open date. The FlexPen was prescribed to Resident #93 and dispensed by the pharmacy on [DATE]. An observation was conducted with Staff D, LPN at 1:09 p.m. on [DATE], of the Oasis Key Medication Cart #2. The observation indicated four insulin pens and one non-insulin pen were opened and noted with an open date: Resident #135's Levemir FlexTouch pen was undated, opened, and dispensed by the pharmacy on [DATE]; Resident #135's Novolog FlexPen was opened, undated, and dispensed on [DATE]; Resident #136's Novolog FlexPen was opened, undated, and dispensed by the pharmacy on [DATE]; Resident #136's Lantus Solostar pen was opened, undated and dispensed on [DATE]. A sticker attached to the pen instructed the user to discard after 28 days; Resident #1's Victoza non-insulin pen was observed opened and undated. The bag where the Victoza pen was stored was a pharmacy-labeled for the resident's Lantus Solostar pen. According to the website: https://www.novonordiskmedical.com/our-products/storage-and-stability.html, a Victoza pen should be discarded 30 days after its first use, a Novolog Flexpen was to be discarded 28 days after its first use or before its first use if left at room temperature, and a Levemir FlexTouch pen should be discarded 42 days after its first use. During an interview at 1:47 p.m. on [DATE], the Consultant Pharmacist stated the unopened an undated insulin should be handled as if they were opened and dated with the date the pharmacy dispensed it. She stated that she would not store the Victoza pen in a Novolog bag; that it should be stored in a bag by itself and the Victoza comes in a box. The Consultant Pharmacist stated she did not have anything to do with the Hospice Comfort kit, found in the Oasis Suites refrigerator. The Director of Nursing stated, on [DATE] at 12:47 p.m., the expectation for opening an insulin pen is that it should be left in the refrigerator until labeled. She stated the Hospice Comfort Kit should have been given to her to destroy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105792 If continuation sheet Page 11 of 18 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 105792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Winter Haven 1510 Cypress Gardens Blvd Winter Haven, FL 33884 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete The policy titled, 5.3 Storage and Expiration Dating of Medications, Biologicals, Syringes, and Needles, last revised on [DATE], indicated that the facility should ensure that all medications and biological's, including treatment items, are securely stored in a locked cabinet/cart of locked medication room that is inaccessible by residents and visitors. The facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. The facility should ensure that the medications and biologicals for each resident are stored in the containers in which they were originally received. The policy identified that the facility should destroy or return all discontinued, outdated/expired, or deteriorated medications or biologicals in accordance with Pharmacy return/destruction guidelines and other applicable law. Event ID: Facility ID: 105792 If continuation sheet Page 12 of 18 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 105792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Winter Haven 1510 Cypress Gardens Blvd Winter Haven, FL 33884 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review the facility failed to store food in accordance with professional standards for food service safety by not ensuring pre-prepped desserts, a peanut butter and jelly sandwich, and a fruit plate with cut melon and grapes were dated, and not ensuring two personal water bottles were not stored in a cooler in the prep area of the kitchen, and that two measuring scoops were not stored in dry good containers. Findings included: On 3/9/21 at 9:27 a.m., a tour of the cooking, cleaning, and storage areas of the kitchen was conducted with the Certified Dietary Manager (CDM). An observation of the reach-in refrigerator located across from the steamer table revealed two cups of an orange whipped dessert on a tray were uncovered and undated. The CDM confirmed the orange whipped desserts and tray were not dated and should be. On the top shelf of the reach-in refrigerator was a peanut butter and jelly sandwich and a fruit plate with cut melon and grapes that were undated. During the tour an observation of the juice/coffee area identified a measuring scoop stored in a container of sugar. The CDM removed it and placed it on top of the container. In an under counter cooler in the prep area of the kitchen, were two opened bottles of water. When asked if the bottles of water should be in the cooler, the CDM stated, Absolutely not. During the continued tour on 3/9/21 an observation of the dry storage area revealed a baking sheet with individual portioned cereals in disposable bowls. The CDM stated that every morning the facility puts out about eight portions. The tray contained 10-15 servings of cereal and was dated 3/2/21. On a shelf, next to the door, was a 22 quart plastic container of flour with a measuring scoop inside it. The CDM confirmed the scoop should not be in the container. The facility policy titled, Food Brought into the Facility from Outside Sources, effective 10/4/2019, which indicated that food is stored, prepared, and distributed in accordance with professional standards for food safety. The facility policy titled, Food Safety, revised 11/28/17, revealed: Food is stored and maintained in a clean safe and sanitary manner following federal, state and local guidelines to minimize contamination and bacterial growth. The Dry Storage section indicated, Scoops will be stored in a manner that does not have the potential to contaminate the food ingredients. For example, scoops will be stored outside of bins or placed in a holder on the side of the bin. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105792 If continuation sheet Page 13 of 18 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 105792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Winter Haven 1510 Cypress Gardens Blvd Winter Haven, FL 33884 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility's Quality Assurance Committee failed to implement an effective plan of action related to behavior monitoring associated with the use of psychotropic medications for three residents (#6, #5, and #4 ) of three residents sampled. Findings included: A review of the facility's plan of correction for the recertification survey ending on 3/12/21 revealed the following measures would be taken to correct the deficient practice which was identified at F758: the Director of Nursing (DON)/designee was to audit residents receiving psychotropic medications to ensure Behavior Monitoring Flowsheets (BMFs) were initiated, nursing staff were educated in the implementation of BMFs if necessary, and weekly audits by Unit Managers to ensure that BMFs were initiated for those residents receiving psychotropics. The policy titled, Quality Assessment and Assurance Committee Meetings, issued 12/20/19 and reviewed 12/28/20, indicated the purpose was to provide guidance for conducting the Quality Assessment and Assurance Committee (QAA) meetings and may include documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities. 1. The admission Record for Resident #6 revealed the resident was admitted on [DATE] and 10/6/18. The admission Record included diagnoses not limited to unspecified single episode major depressive disorder. On 5/11/21 at 11:33 a.m., Resident #6 was observed lying in bed while Staff D, Unit Manager (UM), obtained a blood glucose level and administered the resident's insulin. The May 2021 Order Summary Report for active physician orders as of 5/11/21 for Resident #6 indicated that the resident received the following medication: - Escitalopram Oxalate 10 mg - Give 1 tablet by mouth one time a day for depression. The report did not include a physician order to monitor for side effects or behaviors related to the resident's depression. The May 2021 MAR and Treatment Administration Record (TAR) indicated Resident #6 had received the antidepressant medication as ordered. The BMF for Resident #6 indicated that the behaviors and interventions were to be monitored for the antidepressant medication - Escitalopram. A review of Resident #6's BMF did not indicate a behavior that staff were to be monitoring for related to the administration of an antidepressant medication or that staff had documented any episodes of behaviors, interventions or outcomes for any shift. Resident #6's care plan included the following focuses and interventions: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105792 If continuation sheet Page 14 of 18 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 105792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Winter Haven 1510 Cypress Gardens Blvd Winter Haven, FL 33884 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few - At risk for alteration in mood due to (d/t) dx of depression as evident by mood changes. The interventions instructed staff to administer psychotropic med as ordered and monitor effectiveness of psychotropic med, initiated on 10/28/18 and revised on 3/4/20. 2. The admission Record for Resident #5 revealed the resident was admitted on [DATE]. The admission Record included diagnoses not limited to unspecified dementia with behavioral disturbance, unspecified schizophrenia, other specified depressive episodes, brief psychotic disorder, and unspecified anxiety disorder. On 5/11/21 at 10:58 a.m., an observation was conducted of Resident #5 during the administration of medication by Staff B, LPN. The resident was sitting in a wheelchair and asked the same passerby's how are you and stated to the nurse numerous times that she wanted water. A review of the May 2021 Order Summary Report for active physician orders as of 5/11/21 indicated that Resident #5 had orders for the following medications and side effect monitoring: - Seroquel tablet 25 mg - Give one (1) tablet by mouth two times a day for psychosis *Hold for Sedation,* order date 07/01/20. - Sertraline Hydrochloride (HCl) tablet 50 mg - Give one (1) tablet by mouth at bedtime for depression, ordered 1/23/20. - Xanax tablet 0.5 mg (Alprazolam) - Give one (1) tablet by mouth at bedtime for insomnia, ordered 10/17/19. - Antipsychotic Medication: Seroquel tablet 25 mg. Side Effects: Common - Sedation, drowsiness, dry mouth, constipation, blurred vision, Extrapyramidal reaction, weight gain, edema, postural hypotension, sweating, loss of appetite, urinary retention. Nursing Alert: Tardive dyskinesia, seizure disorder, chronic constipation, glaucoma, diabetes, skin pigmentation, and jaundice. Monitor every shift. Document: (+) if side effects present and write progress note (-) side effects not present. - Anti-Depressant Medication: Sertraline HCl 50 mg Side Effects: Common - Sedation, Drowsiness, Dry Mouth, Blurred Vision, Urinary Retention, Tachycardia, Muscle Tremor, Agitation, Headache, Skin Rash, Photosensitivity (skin), Excess Weight Gain. Special Attention for: Heart Disease, glaucoma, chronic constipation, seizure disorder, and edema. Monitor every shift. Document: (+) if side effects present and write progress note (-) side effects not present. - Anti-Anxiety Medication: Xanax side effects: Sedation, Drowsiness, Ataxia (drunk walk), Dizziness, Nausea, Vomiting, Confusion, Headache, Blurred Vision, and Skin Risk. Nursing Alert: If given with other sedatives or hypnotics and alcohol. Monitor every shift. Document: (+) if side effects present and write progress note (-) side effects not present. The May 2021 MAR identified that Resident #5 was administered the above medications as ordered and that the staff had monitored the side effects of the anti-anxiety, anti-depressant, and antipsychotic medications. The Behavior Monitoring Flowsheet, May 2021, identified that staff were to document if any behaviors had been exhibited for the anti-anxiety, anti-depressant, and antipsychotic medications. The BMF did not specify what behaviors were to be monitored nor did the flowsheet identify the diagnoses (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105792 If continuation sheet Page 15 of 18 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 105792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Winter Haven 1510 Cypress Gardens Blvd Winter Haven, FL 33884 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 0867 Level of Harm - Minimal harm or potential for actual harm related to the administration of the psychotropic medications. The BMF did reveal that staff had not monitored for behaviors related to the antipsychotic medication during the night shift on 5/2 - 5/7 and 5/9-5/10/21, antidepressant medications on 5/2-5/7 and 5/9-5/10/21, and antianxiety on 5/10/21. The BMF identified that staff had not monitored for behaviors related to the antipsychotic and antidepressant medications during the day shift on 5/7 ad 5/8/21 or the evening shift on 5/8/21. Residents Affected - Few Resident #5's care plan indicated the following focuses and interventions: - At risk for change in mood or behavior due to medication condition. The interventions indicated that psychiatric were to be consulted as indicated, - Uses antidepressant medication relate to (r/t) depression. The interventions indicated that staff were to observe for side effects and effectiveness q (every) shift and to observe for and report as needed (prn) adverse reactions to antidepressant therapy. - Uses anti-anxiety medications r/t diagnosis (dx) anxiety. The interventions instructed staff to administer anti-anxiety medications, observe for side effects and effectiveness q shift, and observe for and report prn any adverse reactions to anti-anxiety therapy. - Uses psychotropic medications r/t dx of dementia with behaviors and dx of psychotic disorder with delusions. The interventions instructed staff to administer psychotropic medications and to observe side effects and effectiveness q shift and to observe for and report prn any adverse reactions of psychotropic medications. The care plan did not instruct staff to monitor for Resident #5's behaviors related to the administration of medications. 3. The admission Record for Resident #4 revealed the resident was admitted on [DATE] and 9/29/20. The admission Record for the resident included diagnoses not limited to dementia in other diseases classified elsewhere with behavioral disturbance, unspecified schizoaffective disorder, unspecified psychosis not due to a substance or known physiological condition, unspecified recurrent major depressive disorder, unspecified anxiety disorder, and unspecified insomnia. On 5/11/21 at 10:00 a.m., an observation was conducted of Resident #4's medication administration with Staff C, Licensed Practical Nurse (LPN), while the resident was lying in the bed. A review of Resident #4's Order Summary Report for active physician orders as of 5/11/21 indicated the resident was ordered the following psychotropic medications and corresponding side effect monitoring: -- Clonazepam 0.5 milligram (mg) - Give one (1) tablet by mouth every eight (8) hours for anxiety, ordered 9/29/20. -- Anti-Anxiety Medication: Clonazepam tablet 0.5 mg Side Effects: Sedation, Drowsiness, Ataxia (drunk walk), Dizziness, Nausea, Vomiting, Confusion, Headache, Blurred Vision, and Skin Risk. Nursing Alert: If given with other sedatives or hypnotics and alcohol. Monitor every shift. Document: (+) if side effects present and write progress note (-) side effects not present, ordered 9/29/20. --Seroquel 50 mg - Give one (1) tablet by mouth three (3) times a day for schizoaffective disorder, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105792 If continuation sheet Page 16 of 18 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 105792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Winter Haven 1510 Cypress Gardens Blvd Winter Haven, FL 33884 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 0867 ordered 9/29/20. Level of Harm - Minimal harm or potential for actual harm -- Antipsychotic Medication: Seroquel tablet 50 mg. Side Effects: Common - Sedation, drowsiness, dry mouth, constipation, blurred vision, Extrapyramidal reaction, weight gain, edema, postural hypotension, sweating, loss of appetite, urinary retention. Nursing Alert: Tardive dyskinesia, seizure disorder, chronic constipation, glaucoma, diabetes, skin pigmentation, and jaundice. Monitor every shift. Document: (+) if side effects present and write progress note (-) side effects not present ordered 12/7/2020. Residents Affected - Few The May 2021 Medication Administration Record (MAR) identified that Resident #4 had been administered the above medications as ordered and staff had documented the lack of side effects that the resident had exhibited. The May 2021 Behavior Monthly Flowsheet (BMF) and the behavior/intervention/outcome codes indicated the following: - Anti-psychotic (AP), Seroquel tablet 50 mg for schizoaffective disorder as exhibited by 9, which the behavior legend identified as continuous screaming/yelling. - Anti-anxiety (AA), Clonazepam tablet 0.5 mg for anxiety as exhibited by 4, which the behavior legend identified as anxiety. The BMF did not include documentation that staff had monitored behaviors or interventions related to Resident #4's use of antipsychotic or antianxiety medications. Resident #4's care plan indicated the following focuses and interventions: - At risk for adverse side effects of psychotropic medications, schizoaffective disorder, and requires antipsychotic meds, initiated on 9/3/19 and revised on 4/16/21. The interventions instructed staff to administer psychotropic medications as ordered by physician, observe for side effects and effectiveness every (q) shift, observed for and report as needed (prn) any adverse reactions of psychotropic medications, and observe for occurrence of target behavior symptoms and document per facility protocol. - Has anxiety disorder, initiated on 7/17/20 and revised on 7/29/20. The interventions included administer anti-anxiety medications as ordered by physician and to observe for side effects and effectiveness q shift. Review of the policy titled, 3.8 Psychotropic Medication Use, effective 12/01/07 and last revised on 11/28/16, identified the following procedures: - 7. All medications used to treat behaviors must have a clinical indication and be used in the lowest possible dose to achieve the desired therapeutic effect. All medications used to treat behaviors should be monitored for: -- 7.1 Efficacy, -- 7.2 Risks, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105792 If continuation sheet Page 17 of 18 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 105792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/12/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Life Care Center of Winter Haven 1510 Cypress Gardens Blvd Winter Haven, FL 33884 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 0867 -- 7.3 Benefits, and Level of Harm - Minimal harm or potential for actual harm -- 7.4 Harm or adverse consequences. Residents Affected - Few - 12. Facility staff should monitor the resident's behavior pursuant to Facility policy using a behavioral monitoring chart or behavioral assessment record for residents receiving psychotropic medication for organic mental syndrome with agitated or psychotic behavior(s). Facility staff should monitor behavioral triggers, episodes, and symptoms. Facility staff should document the number and/or intensity of symptoms and the resident's response to staff interventions. At approximately 3:30 p.m., Staff D, UM identified that the BMF did not include any documentation related to the use of Resident #6's antidepressant. During an interview with the Interim Director of Nursing (DON) , she reviewed Resident #4's BMF and confirmed that staff had not documented behaviors related to the resident's anti-anxiety and antipsychotic medications. The DON reviewed Resident #5's BMF and confirmed there were no behaviors listed on the BMF related to the resident's anti-anxiety, antipsychotic, and anti-depressant medications. The DON reviewed Resident #6's BMF and confirmed that staff had not completed the documentation. During an interview, on 5/11/21 at 2:00 p.m., the Consultant Pharmacist stated the facility should be monitoring behaviors. The Consultant stated that each condition should have a behavior, for example: if treating depression with an antidepressant they should have a behavior to monitor. During an interview with the NHA and Interim DON, at approximately 7:00 p.m., they acknowledged that the deficiency was uncorrected. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105792 If continuation sheet Page 18 of 18