Inspection·May 20, 2021

F 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation, interview and record review, the facility failed to post the daily nurse staffing hours. Findings: Residents Affected - Many On 5/19/21 at 11:25 AM, the Required Staffing in 24 Hour Period form was posted at the main entrance desk. The form was dated 5/18/21. The Director of Nursing (DON) acknowledged the date on the form was not current. On 5/19/21 at 11:33 AM, the DON said the Staffing Coordinator was responsible for posting the required form daily. She noted the Staffing Coordinator came to work late that morning and I forgot to change the form. On 05/19/21 at 5:03 PM, the Staffing Coordinator indicated she had the form with the nursing hours ready last night. She said she failed to remind the DON she was coming later that day so the DON could change the nursing staffing hours form. The facility's policy and procedure titled Nurse Staffing Posting Information, revised on 7/20, included, The facility will post the nurse staffing data at the beginning of each shift. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105879 If continuation sheet Page 2 of 5 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 105879 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westminster Winter Park 1111 S Lakemont Ave Winter Park, FL 32792 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to remove an expired medication from 1 of 4 medication carts reviewed during medication storage observation. Findings: On [DATE] at 5:05 PM, during review of the [NAME] Unit Cart #1, a package of Tramadol 50 milligrams (mg) containing 19 pills noted expired on [DATE]. A second package of the same medication, containing 29 pills, showed expired on [DATE]. Both packages belonged to resident #18. Registered Nurse (RN) C said she usually let the supervisor know when there were expired controlled medications but explained she had not realized the Tramadol had expired. Resident #18 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of the brain and polyneuropathy. Tramadol was first prescribed on [DATE] and was last given in [DATE]. The order read, Tramadol 50 milligrams every 8 hours as needed (PRN) for pain. The facility did not ensure resident #18 had Tramadol ready to be used in the event it was needed to treat the resident's pain. On [DATE] at 11:15 AM, the Director of Nursing (DON) said expiration dates should be checked. The DON explained that multiple checks were in place that included the pharmacy technician and nurses before a medication was given to a resident. The DON did not explain why the 2 packets of expired Tramadol were still in the medication cart. On [DATE] at 1:00 PM, the Pharmacy Consultant explained her responsibility included reviewing residents' medications for correct doses, indications, appropriate utilization, interactions, duplications, and duration of times. The Pharmacist Consultant added she evaluated PRN medications for duration of time and appropriateness. She said the nurse should check the expiration dates before giving the medication. The facility's policy and procedure titled, Medication Administration, revised on 7/20, included, Identify expiration date. If expired, notify nurse manager. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105879 If continuation sheet Page 3 of 5 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 105879 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westminster Winter Park 1111 S Lakemont Ave Winter Park, FL 32792 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 - Some 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 monitor the temperatures for cold preparation room refrigeration, failed to maintain the walk-in freezer in good repair to prevent food contamination, failed to maintain cleanliness of the 1st floor ice machine and the 2nd floor ice chest and failed to have a functioning pressure gauge and monitor pressures for high temperature dish washing machine. Findings: 1. On 5/17/21 at 9:29 AM, the cold preparation kitchen was observed with the Dining Services Director (DSD). The produce refrigeration temperature was observed by the surveyor at 50 °F (degrees Fahrenheit). Review of the temperature log revealed the last documented temperature of the refrigeration was the morning of 5/15/21. The DSD said the refrigerator temperatures should be monitored twice daily to ensure safe storage temperature of food. He acknowledged he had not looked at the temperature logs today and was not aware the refrigeration temperatures had not been completed on the weekend. He explained, without monitoring the refrigeration daily you cannot ensure the food was safe. 2. On 5/17/21 at 9:56 AM, the walk-in refrigerator and freezer were located outside on the dock area. The entry to the freezer was inside the walk-in refrigerator. The freezer door was completely closed but it did not seal properly. The freezer door had condensation and ice build-up around the bottom corners of the door. The Chef stated the last time he looked at the freezer, it was in the same condition. Upon opening the door, there was ice build-up around the entire inner frame of the door. The freezer evaporator fans were blocked by boxes of food items stored on the shelf in front of the fan. The ceiling of the freezer had multiple icicles approximately 1 inch long hanging down over boxes of food items. The shelf under the fan had a tray filled with ice from water that had dripped from the fan. The Chef said it was a recurring problem. The Chef and the DSD acknowledged the observation of ice around the inner seal of the freezer door and the condition of the freezer. They said they did not know how long the freezer door had been in this condition. They said they had not had any recent service calls for the repair of the walk-in freezer. 3. On 5/17/21 at 3:16 PM, observation of the 1st floor pantry had an ice machine used to provide ice to the residents. The ice machine drain rack had a white chalky build- up. The ice chute also had the white build-up and black biofilm substance where the ice was dispensed. The last maintenance date of the machine was illegible. On 5/17/21 at 3:28 PM, observation of the 2nd floor pantry revealed the ice machine was out of order. An ice chest was filled with ice to be served to the residents. The interior rim of the chest had a pink biofilm substance present. Review of the refrigeration service company's quarterly preventative maintenance of the ice maker and water filters noted the last service for the 1st floor machine was 2/05/21. The 2nd floor ice maker preventative maintenance report noted that it was completed on 5/13/21. It was not functioning on 5/17/21. On 5/18/21 at 10 AM, the DSD said he was not sure who was responsible for monitoring the daily cleaning of the ice machines and ice chest. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105879 If continuation sheet Page 4 of 5 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 105879 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/20/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westminster Winter Park 1111 S Lakemont Ave Winter Park, FL 32792 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 - Some 4. On 5/18/21 at 4:30 PM, observation was conducted of the high temperature dishwashing machine. The Dining Services Technician read the water temperatures during operation of the machine. The pre-wash temperature was 148 °F, wash temperature was 160 °F, and the final rinse temperature was 185°F. The pressure gauge of the high temperature dish machine was broken, and pressure of the final rinse was not readable or functioning. The Dining Technician said he did not know anything about the pressure gauge or that it was required for monitoring of sanitization of the dishware. Review of dish washing machine monitoring log documented temperatures of the wash and rinse cycles. The last column of the log indicated sanitizer should be monitored. The machine was a high temperature machine that did not require sanitizer. The final rinse pressure should have been monitored to ensure thorough sanitation of the dishware. Interview with the Dining Services Director on 5/18/21 at 4:40 PM, revealed he was not aware the pressure of the final rinse needed to be monitored to ensure proper sanitization of dishware. Review of the manufacturer's specification sheet noted operating temperature should be wash 160°F, rinse 180°F, and water flow pressure 15-25 pounds per square inch (PSI). Review of Food and Drug Administration Food Code 2017 Chapter 4-501.113 Mechanical Ware washing Equipment, Sanitization Pressure. The flow pressure of the fresh hot water sanitizing rinse in a warewashing machine, as measured in the water line immediately downstream or upstream from the fresh hot water sanitizing rinse control value, shall be within the range specified on the machine manufacturer's data plate and may not be less than 35 kilopascals (5 PSI) or more than 200 kilopascals (30 PSI). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105879 If continuation sheet Page 5 of 5