Inspection·January 26, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 1. During facility tours on 01/23/23 at 10:16 a.m., 01/24/23 at 11:25 a.m., and on 01/25/23 at 08:45 a.m., an observation was made of Resident #103's catheter that was visible from the hallway. Resident # 103 was noted laying on his bed, unaware his catheter was visible to everyone walking down the hallway. The resident's door was wide open and the privacy curtain was pulled to the head of the bed. In an interview with Resident #103 on 01/25/23 at 08:45 a.m., the resident stated he did not know his catheter was visible to passersby in the hallway. The resident stated it was no one's business to see his catheter. Resident #103 said, I'd like it covered. A review of Resident #103's electronic medical record (MAR) showed the resident was admitted to the facility on [DATE] with diagnoses to include: neuromuscular dysfunction of the bladder, encounter of artificial openings of urinary tract and malignant neoplasm of bladder. A review of the physician orders for Resident #103 dated 01/25/23 showed an order dated 08/28/22 indicating urostomy device to straight drainage due to a diagnosis of bladder cancer. A review of a quarterly Minimum Data Set (MDS) dated [DATE] showed Resident #103 had a brief interview for mental status (BIMS) score of 14, indicating intact cognition. Section G, functional status showed Resident #103 required extensive assistance for Activities of Daily Living (ADLs) including toilet use. Section H indicated the resident had an ostomy (including urostomy, ileostomy and colostomy). A care plan dated 01/06/23 showed a focus indicating the resident had impaired bladder function related to a history of prostate cancer and had a urostomy present. Interventions included catheter care every shift. On 01/25/23 at 08:46 a.m., an interview was conducted with Staff C, Licensed Practical Nurse (LPN) Unit Manager. Staff C made the observation of Resident #103 from the hallway outside the resident's door. Staff C stated, that is not good, we should ensure a more dignified living. Staff C stated the resident's catheter should not be exposed to the public. She stated they should probably move it to the other side of the bed for privacy. Staff C stated the privacy flap should be pulled over to cover the output. Staff C stated they would switch out the catheter to one that provided privacy. She stated she had spoken to the certified nurse's aide (CNAs) and nurses. She stated in-servicing staff was a never-ending job. Staff C said, we owe it our residents. Staff C confirmed resident's catheters should not be exposed to the public. On 01/25/23 at 12:40 p.m., an interview was conducted with the Director of Nursing (DON). She stated Staff C had notified her there was a catheter that was exposed. The DON stated it was their goal to ensure resident's privacy was respected. She stated catheters should not be within sight of anyone walking down the hall. The DON confirmed a privacy bag should be provided for all residents with catheters. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105792 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 105792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. A review of Resident #63's medical record revealed Resident #63 was admitted to the facility on [DATE] with diagnoses of psychosis, diabetes mellitus, and major depressive disorder. Resident #53 had a diagnosis of unspecified dementia added to the medical record on 11/6/2019. A review of Resident #63's Preadmission Screening and Resident Review (PASARR) dated 8/6/2013 revealed no qualifying mental health diagnosis and no PASARR Level II was required. A review of Resident #63's Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 12/27/2022 revealed, under Section I: Active Diagnoses, diagnoses of Non-Alzheimer's Dementia, anxiety disorder, depression, and psychotic disorder. Review of Resident #63's medical record revealed the resident was not assessed for PASARR Level II. 6. A review of the admission Record revealed Resident #94 was admitted on [DATE] with diagnoses of delusion disorders and psychotic disorder with delusions due to known physiological condition. A review of Resident #94's PASARR Level I assessment dated [DATE] revealed no qualifying mental health diagnosis and no PASARR Level II was required. A review of Resident #94's medical record revealed a new diagnosis of unspecified dementia, unspecified severity, with psychotic disturbance. A review of Resident #94's Quarterly Minimum Data Set (MDS) dated [DATE] revealed a diagnosis of psychotic disorder and the resident was not assessed for PASARR Level II. Review of a facility policy titled, Preadmission Screening and Resident Review (PASARR), revised 10/06/22, showed the facility will ensure that potential admissions are screened for possible serious Mental Disorders (MD) or Intellectual Disabilities (ID) and related conditions. This initial prescreening is referred to as PASARR level I and is completed prior to admission to a nursing facility. A negative level I screen permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. A positive level I screen necessities an in-depth evaluation of the individual by the state's designated authority known as PASARR level II which must be conducted prior to admission to a nursing facility. Under procedure: (1.) Ensure level I PASARR screening has been completed on potential admissions prior to admission. (5.) When a level II PASARR screening is warranted, it must be obtained as well as determination letter prior to admission. The level II PASARR cannot be conducted by the nursing facility. (13.) Any resident with newly evident or possible serious mental disorder, intellectual disability or a related condition must be referred by the facility to the appropriate state designated mental health or intellectual disability authority for review. (14.) Referral for level II resident review evaluation is required for individuals previously identified by PASARR to have a mental disorder, intellectual disability, or a related condition who experiences significant change. Based on record review, staff interviews, and review of the facility's policy, the facility failed to complete the Preadmission Screening and Resident Review (PASARR) Level II upon a new qualifying mental health diagnosis for six (Residents #40, #78, #95, #55, #63 and #94) of seven residents (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105792 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 105792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 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 0644 sampled for PASARR Level II. Level of Harm - Minimal harm or potential for actual harm Findings included: Residents Affected - Many 1. A review of the electronic medical record (EMR) revealed Resident #40 was admitted to the facility on [DATE]. A Minimum Data Set (MDS) dated [DATE], showed in section I, Resident #40 was admitted with diagnoses of Depression and Schizophrenia. A review of a quarterly MDS dated [DATE] Section I showed the resident had current diagnoses of Depression and Schizophrenia. Review of Resident #40's PASSAR Level I screen dated 11/24/20 revealed no qualifying mental health diagnosis was indicated and no PASARR Level II was required. A Care plan dated 12/29/22 showed a goal initiated on 06/28/21 indicating the resident had actual risk for behavioral deficits and was combative towards staff. A goal initiated 12/04/20 showed the resident had potential risk for ineffective coping related to schizophrenia and bipolar. A goal initiated on 9/822 showed the resident had a diagnosis of Dementia. The record review showed a level II PASARR evaluation was not completed for a resident with a history of dementia and suspicion of a serious mental illness. A pharmacy consultation report dated December 1, 2022 through December 19, 2022 showed Resident #40 had recommendations related to a newly added psychiatric diagnosis of bipolar on 11/30/22. The pharmacy note showed: there is a diagnosis on file of schizophrenia, but not clear documentation of disease history. The 2020 history and physical shows a history of dementia. Recommendations from the pharmacy report showed: Provide additional documentation in the medical record that clarifies the diagnosis and indication of use. 1. The specific s/s (signs/symptoms) being treated for this indication or that led to this diagnosis. 2. The impact of the resident (e.g., increased distress, hallucinations, dangerous behaviors) 3. Documentation that causes (e.g., environmental, other medical conditions) and meds have been ruled out and that individualized non-pharmacological interventions are in place. Physician response dated 12/21/22 showed: per family history she has had mood swings and a strong family history of mental illness. A review of a psychiatry progress note dated 12/21/22, revealed [the] resident has a history of aggression with significant history of Mental illness. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105792 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 105792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 01/25/23 at 12:28 p.m., an interview was conducted with the facility's Psychiatrist. The psychiatrist stated Resident #40 was being treated for mood disorder. She stated the resident came in with a Schizophrenia diagnosis. Resident #40 had paranoia and used to be aggressive towards staff and had Olanzapine reduced. She stated the resident's family member confirmed she was diagnosed with Schizophrenia. The Psychiatrist confirmed she diagnosed her [Resident #40] with Bipolar because of the mood swings. She stated on 06/21/22 she had discussed the resident's psych history with the family and learned the resident had a significant history of mental health and was [NAME] Acted from another facility due to Suicidal ideation. The psychiatrist confirmed if a resident's diagnosis changed, their PASSAR should be reviewed I suppose. She stated if a resident had a significant history of mental health, the PASSAR should reflect that. A review of the medical record for Resident #40 revealed the resident was not assessed for PASARR Level II. 2. A review of the electronic medical record (EMR) revealed Resident #78 was admitted to the facility on [DATE]. Review of an admission MDS dated [DATE] section I showed Resident #78 was admitted with a diagnosis of bipolar disorder. A review of the quarterly MDS dated [DATE] section I, showed Resident #78 had a new diagnosis of anxiety disorder. A review of Resident #78's PASARR Level I screen dated 11/08/19 revealed no qualifying mental health diagnosis was indicated, and no PASARR Level II was required. A review of the medical record revealed the resident was not assessed for PASARR Level II. 3. A review of the electronic medical record (EMR) revealed Resident #95 was admitted to the facility on [DATE]. A review of an MDS dated [DATE] section I showed Resident #95 had a diagnoses of anxiety disorder and depression. A review of Resident #95's PASARR Level I screen dated 09/15/17 revealed no qualifying mental health diagnosis was indicated, and no PASARR Level II was required. A review of a document for Resident #95 titled, Resident information, dated 1/25/23, showed the resident had new diagnoses to include: mood disorder due to unknown psychological condition, bipolar disorder, and major depressive disorder. A review of the medical record revealed the resident was not re assessed for PASARR Level I upon admission or PASARR Level II upon acquiring new diagnosis. 4. Review of the electronic medical record (EMR) revealed Resident #55 was admitted to the facility on [DATE]. A review of an admission MDS dated [DATE] section I showed Resident #55 was admitted with diagnoses of bipolar disorder and depression. A review of a quarterly MDS dated [DATE] section I showed Resident #55 had diagnoses of bipolar disorder and depression. A review of a document for Resident #55 titled, Resident information, dated 01/25/23, showed the resident had new diagnosis of schizoaffective disorder. A review of Active Physician Orders for Resident #55 dated 1/25/23, showed the resident was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105792 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 105792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm prescribed Ziprasidone HCI Oral capsule 80 mg (Ziprasidone HCI), give 1 capsule by mouth two times a day for schizoaffective, dated 01/18/23. A review of Resident #55's PASARR Level I screen dated 8/19/21 revealed a qualifying mental health diagnosis was not indicated, and no PASARR Level II was required. Residents Affected - Many A review of the medical record revealed the resident was not assessed for PASARR Level II following the new diagnosis. On 01/25/23 at 12:32 p.m., an interview was conducted with the Social Services Director ( SSD). She stated she reviewed PASARRs to make sure they were current and looked for diagnoses to make sure all current diagnosis were checked. She said after reviewing she notified the physician of any discrepancies to make sure they collaborated with psychiatry. The SSD stated she confirmed the diagnoses were current to ensure we were meeting the needs of the patient. If there was a problem or if a diagnosis was missing, she would notify the Director of Nursing (DON). The SSD reviewed the PASARRs for the sampled residents and said, diagnosis should be checked. I probably missed them. If a resident obtained a new diagnosis, a new PASARR should be obtained. The SSD stated she would discuss the findings with the DON. On 01/25/23 at 1:09 p.m., an interview was conducted with the DON. She stated PASARRs were completed prior to admission. She stated in the morning meeting all the departments review the new admission file. The SSD reviewed the PASSAR to make sure it was good, meaning current diagnoses were checked, content was complete, and to ensure accuracy of the content. The DON stated the SSD was reviewing resident files on an-ongoing basis, for completeness and accuracy. She stated following survey findings, they discussed the PASARRs and noted some were missing documented diagnoses, or they were not checked. She stated they would be reviewing in the morning meeting going forward to make sure current PASARRs were accurate and to see if we need to adjust. The DON said, if a resident had a new diagnosis, it should be reflected. We should submit a new PASARR for each new diagnosis. The clinical team would be reviewing this on an-going basis. The DON confirmed if a resident had a new significant mental health change, a level II PASARR should be submitted for review. DON stated they will be resubmitting those today for review. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105792 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 105792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 01/23/23 at 11:45 a.m., Resident #94 was observed in bed. An attempt to interview the resident was unsuccessful. Resident #94's right hand and arm were observed bruised. The right hand had an undated bandage partially covering the bruise (photographic evidence obtained). Residents Affected - Few On 01/23/23 at 3:30 p.m., Resident #94 was observed in the dining area, outside of the nursing station, with three undated dressings, one to the right arm and two on the left arm. The resident's assigned nurse was interviewed and stated she did not know why the resident had the bandages but she would look. On 01/25/23 at 9:50 a.m., Resident #94 was observed in bed with no bandages on her hands or arms. The admission Record revealed Resident #94 was initially admitted into the facility on [DATE] with a primary diagnosis of Parkinson's Disease. Section C Cognitive Patterns of the Minimum Data Set (MDS) dated [DATE] indicated the resident was not able to complete the Brief Interview for Mental Status. A review of the Order Summary Report with active orders as of 01/25/23 revealed the following orders related to skin: Adaptive Device: Resident will wear bilateral palm guard splints 6 hours during the day to reduce fisted hand position and to prevent skin breakdown and to prevent contractures. Apply house lotion to bilateral arms and legs daily. Skin check to be completed and documented in the weekly skin check assessment. Treatment: Cleanse left forearm with Normal Saline (NS), pat dry, apply xeroform, cover with kerlix roll and tape three times per week and PRN (as needed) until resolved. Resident #94 did not have a treatment order in place related to skin impairment for the right hand or right arm. The document provided by the facility Incident by Incident Type dated 07/23/22 to 01/23/23 did not reflect any incidents for Resident #94. A care plan related to skin impairment initiated on 11/04/20 included but was not limited to the following intervention: treatment as/if ordered. On 01/25/23 at 9:50 a.m., Staff C, Licensed Practical Nurse (LPN), Unit Manager (UM), reported Resident #94 had an order in place to keep her in long clothes because she bumps against things and she had very fragile skin. Staff C stated she would have to look up the orders because she was not the nurse on the floor. The resident had Geri sleeves. The nurse reported she only saw an order for treatment to the left forearm in the resident's medical record. On 01/25/23 at 10:03 a.m., Staff C, LPN, UM, stated she looked at the orders and only saw an order (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105792 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 105792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 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 0684 for the left arm. She stated the bandages should be dated and there should be an order for treatment. Level of Harm - Minimal harm or potential for actual harm Review of a facility policy titled, Skin Integrity and Pressure Ulcer/injury prevention and Management, reviewed 04/19/22, showed the facility intends to provide associates and licensed nursed with procedures to manage skin integrity, prevent pressure ulcer/injury, complete wound assessment / documentation and provide treatment and care of skin and wounds utilizing professional standards. Under procedure, Skin observations occur throughout points of care provided by CNAs during an Activities of Daily Living (ADL) care. Any changes or open areas reported to the nurse. CNAs will also report to nurse if topical dressing is identified as soiled, saturated, or dislodged. Nurse will complete further inspection/assessment and provide treatment if needed. Residents Affected - Few Based on observations, interviews and record review, the facility did not ensure assessments and treatments were provided for two (Residents #49 and #94) of three residents reviewed for skin conditions. Findings included: 1. On 01/23/23 at 1:30 p.m., Resident #49 was observed with an undated dressing on her upper right arm. The dressing was noted with two small blood spots on the lower end of the dressing. The resident was noted to have another undated dressing on the front of her elbow on the upper right arm. The resident was not able to stretch out her arm. Resident #49 stated she had an incident with staff during a therapy session where her arm was caught on the door. The resident could not verify the timing of the incident. The resident stated since that incident, the dressing on her arm had not been changed. Review of a facility document titled, incident by incident type, dated 07/23/22 to 01/23/23 revealed the incident related to Resident #49's arm injury was not documented. Resident #49 was re-admitted to the facility on [DATE]. A quarterly minimum data set (MDS) dated [DATE] showed under section C, the resident had a brief interview for mental status (BIMS) score of 15, indicating intact cognition. Section G, functional status showed the resident was dependent on Staff and required extensive assistance for all activities of daily living (ADLs). Review of weekly skin integrity data collections showed: 01/23/23: skin intact, no new findings. Bruising to upper and lower extremities. Skin tear to right arm and left arm. 01/16/23: skin is intact, no new findings. Bruising noted to upper and lower extremities. 01/09/23: skin intact, no new findings. Bruising to upper and lower extremities. Edema noted to lower extremities, skin tear to right arm dressing in place. 01/02/23: skin intact, no new findings. Bruising to upper and lower extremities. Patient on blood thinner, skin tear to right forearm treatment in place. The review of skin assessments showed on-going concerns with bruising and skin tears. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105792 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 105792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 01/24/23 at 11:17 a.m. an interview was conducted with Resident #49. The resident stated her arm was hurting and no one had looked at it. The resident re-stated she was hurt when she was being transported to therapy. Resident #49 stated a nurse had put a dressing on the arm and no one had looked at it since then. The dressings were noted on the resident's arm, undated and with blood spotting visible to the surface. Review of the Physician orders dated 01/25/23 showed the resident did not have any orders to treat the skin tears and bruising. The review showed orders were initiated on 01/25/23 after this surveyor notified the facility of concerns. The new orders showed to clean right arm with normal saline, pat dry, and apply clean border dressing, leave in place for two days then remove and leave open to air. Review of a Medication Administration Record (MAR) for Resident #49 showed the resident was not receiving any treatment for the skin tears and bruising. On 01/25/23 at 8:45 a.m., an interview was conducted with Staff C, Licensed Practical Nurse (LPN) Unit Manager and Resident #49. Staff C observed the resident and stated she did not know why the resident had the undated dressings on her right arm. Staff C stated she was not aware of any incidents that may have caused the resident's injuries. She stated either way the dressings should be dated. Whoever put them on should have said something. Resident #49 stated the dressings had been on her arm for 2 to 3 weeks from an incident that happened when she was being assisted to therapy. The resident stated her arm got caught on the door and was bleeding from the injury. Resident #49 stated a nurse cleaned her up and put the bandage on. On 01/25/23 at 9:58 a.m., an interview was conducted with Staff C. Staff C stated the resident did not have any orders to treat the bruising. Staff C stated the nurse who was notified of the injury should have reported and contacted the physician to obtain orders. Staff C stated if the resident had orders in place, the wound care nurse would have looked at her and treated the skin tears. Staff C removed the dressing on the lower right arm revealing a dry scabbed area with dried blood. Staff C attempted to pull the second dressing off the upper right arm. Staff C stated she would have wound care assess her. Staff C said, It looks like she is still bleeding. Staff C stated she would contact the physician to obtain orders to treat. On 01/25/23 at 10:08 a.m., an interview was conducted with Staff C who reviewed the resident's orders and confirmed the resident did not have any orders to treat the skin tears. She stated the nurses should always obtain physician orders prior to treating. She stated an incident report should have been completed detailing the incident. Staff C confirmed the resident was still bruised and bleeding. Staff stated she will conduct an evaluation and follow-up with orders to treat. On 01/25/23 at 11:30 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated she just became aware the resident had an incident during therapy a few weeks ago. She stated she just spoke to the Director of Rehabilitation (DOR) and notified her if there was ever an injury incident in her department, she needed to submit a report and notify administration. The DON stated the DOR notified a nurse who put a dressing on the resident. She did not remember who it was. The DON stated the expectation was to assess the resident, obtain orders to treat if needed, and to report an injury incident . She stated the incident should have been documented and wound care should have been looking at her. The DON stated they were initiating an investigation. The DON confirmed the dressings should be dated. The DON stated anyone, a nurse or a certified nurses' aide (CNA) should have noted the bleeding dressing and done something about it. She stated they had educated all nurses (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105792 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 105792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 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 0684 who were in house and would continue to in-service. 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: 105792 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 105792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility did not ensure respiratory equipment was stored in a sanitary manner for six (Resident #40, #118, #14, #51, #49 and #103) of eight residents reviewed for respiratory care. Residents Affected - Some Findings included: 1. During facility tours on 01/23/23 at 9:35 a.m., 01/24/23 at 11:15 a.m. and 01/25/23 at 8:22 a.m., Resident #40 was observed in her room in bed. An oxygen concentrator was noted at the head of her bed. The tubing and cannula were tucked on the handle and hung down to the floor. The tubing and cannula were not bagged. Resident #40 did not respond to the interview. Resident # 40 was admitted to the facility on [DATE]. Review of current physician orders dated 01/25/23 showed the resident did not have orders to administer oxygen. 2. On 01/23/23 at 10:34 a.m., 01/24/23 at 9:15 a.m. and 01/25/23 8:33 a.m., an observation was made of Resident #118's CPAP (continuous positive airway pressure ) device stored on top of a bedside table with the mask and tubing lying on top of personal items. The mouthpiece and tubing were exposed to the elements. On 01/25/23 at 8:33 a.m., an interview was conducted with Resident #118. The resident said, They leave the mouthpiece open to the dust, it's kind of nasty. They don't change it most of the time. The resident stated the mask was normally dirty because they did not clean it. A review of active physician orders for Resident #118 dated 01/25/23, showed the resident had orders for CPAP on while sleeping/napping and off while awake every shift for respiratory. On 01/25/23 8:35 a.m., an interview was conducted with Staff C, Licensed practical nurse (LPN)/ unit manager. Staff C observed the CPAP on top of the nightstand and stated she told the nurses to make sure it was bagged all the time. She stated she expected the nurses to wash the mouthpiece and put it in a bag. Staff C stated the tubing and masks should be changed as ordered, it should be changed weekly. 3. On 01/23/23 at 9:30 a.m., Resident #49's oxygen tubing and cannula were observed hanging on top of the concentrator. A travel oxygen tank was observed on back of her wheelchair with the tubing dangling to the side. The nebulizer mask was observed on top of the resident's bedside table uncovered. This observation was also made on 01/24/23 at 11:20 a.m. and 01/25/23 8:45 a.m. Resident #49 was admitted to the facility on [DATE] with a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD). Active physician orders for the resident showed Oxygen sat (saturation) rates every shift and Ipratropium - albuterol solution 0.5 - 2.5 (3) MG/ML 3 ml inhale orally via nebulizer every 6 hours for COPD. 4. On 01/23/23 at 11:02 a.m., an observation was made of an oxygen concentrator stored on the side of Resident #14's bed. The cannula and tubing were hanging on the concentrator tank, with cannula exposed to the elements. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105792 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 105792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On at 01/24/23 9:29 a.m., an interview was conducted with Resident #14. She stated she used the oxygen as needed, but it had been a while. The resident stated she had forgotten it was there. She stated when she used the oxygen, staff assisted her with it. Resident #14 was admitted to the facility on [DATE]. A review of her current physician orders showed no orders to administer oxygen. On 01/25/23 at 9:50 a.m., an interview was conducted with Staff C. Staff C observed the resident's oxygen equipment at bedside. She stated she had been trying to educate the nurses. Staff C stated, Respiratory equipment should be stored in bags and dated because it is unsanitary. The equipment should not be left to the open like that. Staff C stated she would initiate another in-service. In an interview on 01/25/23 at 10:12 a.m., Staff C stated the residents should have current respiratory orders and if the order was discontinued, the equipment should be removed from the room. 5. On 01/23/23 at 10:16 a.m., an observation was made of Resident #103's of a nebulizer machine on the resident's window sill. The mask was resting on the blinds, uncovered, and exposed to the elements. Resident #103 was admitted to the facility on [DATE] with diagnoses to include COPD. A review of active physician orders for Resident #103 showed ipratropium albuterol inhale orally every 6 hours for COPD. 6. During a tour on 01/23/23 10:29 a.m. and on 1/24/23 at 9:23 a.m. An oxygen concentrator was observed on the side of the Resident #51's bed. The tubing and nasal cannula were observed tucked into the concentrator tank handle with the cannula exposed to the elements. A review of Resident #51's record showed he was admitted to the facility on [DATE] with diagnoses to include COPD. A review of the current physician orders dated 01/25/23 showed the resident did not have current oxygen orders. On 01/25/23 at 8:21 a.m., an interview was conducted with Resident #51. He stated he used the oxygen as needed. He confirmed he had used the oxygen within the previous week. A follow -up was conducted on 01/25/23 at 09:50 a.m. an interview was conducted with Staff C. She made the observation of the resident's equipment at bedside with tubing hanging over the tank and tubing exposed to the element. Staff C stated she has been trying to educate the nurses. She stated respiratory equipment should be stored in bags and dated because it is unsanitary. On 01/25/23 at 11:30 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated the facility had a Respiratory Therapist (RT) who should be reviewing all the residents who were on oxygen and confirm orders were in place, to include PRN (As needed) use. She stated the RT was supposed to go around weekly and confirm all equipment was working, properly set, and properly stored. The DON stated the Central Supply department was responsible for changing out all tubing and masks on Sundays. She stated the nurses should be cleaning the equipment after each use and ensure it was stored in a dated bag. She stated she would reiterate the process. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105792 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 105792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Review of a facility policy titled, oxygen administration/safety/storage/maintenance, issued 12/03/22, showed oxygen will be administered in accordance with physician orders and current standards of practice. Under infection control: #3. Store oxygen and respiratory supplies in a bag labeled with resident's name when not in use. #5. If oxygen is discontinued, discard all disposable pieces including filters (replace with new ones). Training requirements: all staff shall be educated on oxygen administration safety and storage upon hire annually and as indicated thereafter. Event ID: Facility ID: 105792 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 105792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 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 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 interviews and record reviews, the facility failed to ensure behavioral and side effect monitoring related to the use of psychotropic medication was completed for one (Resident #32) of five residents sampled for unnecessary medication use. Findings included: A review of Resident #32's medical record revealed Resident #32 was admitted to the facility on [DATE] with diagnoses of dementia, anxiety disorder, and mood disorder. A review of Resident #32's physician's orders revealed an order, dated 1/18/2023 for Lorazepam 0.5 milligrams (mg) by mouth twice a day for anxiety and every 24 hours as needed for anxiety. Resident #32's physician's orders did not reveal orders for monitoring of behaviors or side effects related to use of Lorazepam. An interview was conducted on 1/25/2023 at 12:10 p.m. with Staff E, Licensed Practical Nurse (LPN). Staff E, LPN stated Resident #32 was prescribed Lorazepam both as needed and routinely and residents receiving psychotropic medications were monitored for any behavioral changes and side effects of the medication being used. Staff E, LPN reviewed Resident #32's physician's orders and confirmed Resident #32 did not have orders for monitoring of behaviors or side effects related to use of Lorazepam. Staff E, LPN stated Resident #32 should have an order for behavioral and side effect monitoring related to use of Lorazepam and the nurse who put the medication order in the electronic medical record should also put the orders in for monitoring. An interview was conducted on 1/25/2023 at 1:20 p.m. with the facility's Director of Nursing (DON). The DON stated behavioral monitoring related to use of psychotropic medications should be conducted to observe for any type of behavioral symptoms the resident may have, which would be documented in the resident's medical record every shift. The residents using psychotropic medications should also have an order in place for monitoring of side effects related to the specific class of medication being used, which was recorded in the resident's medical record every shift. The DON stated the orders for behavioral monitoring and side effect monitoring should be in place at the same time the medication was ordered. A telephone interview was attempted on 1/26/2023 at 11:08 a.m. with the facility's Consultant Pharmacist. A voicemail message was left for a return call, but the call was not returned. A review of the facility policy titled Psychotropic Medication Use, last revised on 10/24/2022, revealed under the section titled Procedure psychotropic medications to treat behaviors will be used appropriately to address specific underlying medical or psychiatric causes of behavioral symptoms. The policy also revealed facility staff should monitor the resident's behavior using a behavioral monitoring chart or behavioral assessment record for residents receiving psychotropic medications. Facility staff should monitor behavioral triggers, episodes, and symptoms and should document the number and/or intensity of symptoms and the resident's response to staff interventions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105792 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 105792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 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 Based on observations, record reviews, and interviews, the facility failed to ensure the medication error rate was less than 5%. Twenty nine medication opportunities were observed and two errors were identified for Resident #107 resulting in an error rate of 6.9% Residents Affected - Few Findings included: On 01/24/23 at 9:04 a.m., Staff D Licensed Practical Nurse (LPN) was observed administering medication to Resident #107. Staff D administered the following medications. -Vitamin C D5200 (mg) -Loratadine 10 mg - MVI (reg) 1 tablet -Fluticasone-Salmeterol Aerosol 100-50 micrograms/activation (mcg/act) 2 inhalations -Ferrex 150 -Lisinipril 10 mg -Sildenafil 20 mg -Oxybutynin ER 5 mg Following the medication administration observation, a review of the physician's orders for Resident #107 revealed there was no order for Loratadine 10 mg. The resident had a physician's order dated 09/15/2022 for Cetirizine (Zyrtec) 10 mg by mouth one time a day for allergies. A review of physician's order dated 09/15/2022, revealed an order for Fluticasone-Salmeterol Aerosol Powder Breath Activated 100-50 mcg/act, 1 inhalation, inhale orally every 12 hours for COPD Rinse mouth after using inhaler. Staff D was interviewed on 01/24/23 at 2:26 p.m. and stated, resident prefers Claritin (Loratadine) and he will tell you what works for him. Staff D stated Zyrtec (Cetirizine) was not even stocked on the cart. She said, The order was wrong and I gave the medication the resident prefers. Staff D said she would call the doctor and have the medication changed. During the interview Staff D confirmed she did not instruct the resident on the use of the inhaled medication. Record review showed that on 1/24/23 at 1430 (2:30 p.m.) the order for Cetirizine was discontinued, and an order was written for Loratadine tablet 10 mg by mouth one time a day for allergy. On 01/24/23 at 2:43 p.m. the Director of Nursing (DON) stated the resident should get the medication per the order and would talk with staff. The DON was informed the nurse handed the resident the inhaler without providing instruction. The DON stated, Residents should always be instructed when administering meds. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105792 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 105792 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 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 A follow up interview with the DON was conducted on 01/25/23 at 8:38 a.m. The DON said she spoke to [Staff D] who made the errors and [Staff D] confirmed she gave medication that was not ordered in favor of what the resident wanted. Staff D also confirmed to the DON she did not instruct the resident how to use the inhaled medication. A voicemail was left for the consultant pharmacist on 01/26/23 at 11:10 a.m. No return call was received by completion of the survey. Review of the Facility's Pharmacy Services and procedure manual section 3.3.7 states Facility staff should verify the medication name an dose are correct when compared to the medication order on the medication administration Record. Section 5.5.7 Provide the resident with any necessary instructions (e.g., using and inhaler). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105792 If continuation sheet Page 16 of 16