Inspection·March 30, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review and interview, the facility failed to develop a comprehensive care plan for one of one resident, (#82) reviewed for death in the facility. Resident #82 had an identified swallowing problem and the Speech-Language Pathologist had recommended compensatory strategies which were not included in the resident's comprehensive care plan. The resident had a choking incident on 2/10/23, and despite the facility staff and Emergency Medical Services emergency efforts, the resident died. Findings: According to the medical record of Resident #82, he was originally admitted to the facility on [DATE] and most recently readmitted on [DATE]. The resident died on 2/10/23. Resident #82 had multiple medical diagnoses, including Parkinson's disease; oropharyngeal phase dysphagia (swallowing problem involving the throat and pharynx); elevated blood cholesterol, high blood pressure, hypothyroidism, atherosclerotic heart disease of the native coronary artery without angina pectoris (heart disease in which plaque builds up in the arteries, causing them to narrow and reducing blood flow without causing pain); heart failure; pulmonary hypertension (a type of high blood pressure that affects the arteries in the lungs and the right side of the heart); other seizures, major depressive disorder, recurrent, mild, unspecified; colostomy status; enterocolitis due to Clostridioides difficile (a bacterium that causes an infection and inflammation of the intestines); mild protein-calorie malnutrition; and chronic pulmonary obstructive disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Resident #82 had a physician's order dated 10/12/22 Regular texture. Regular/thin liquids consistency (diet/thin liquids finger food for independent dining). On 10/13/22, the diet order was changed to Regular texture, nectar thick liquids (Diet/nectar thick liquids finger foods for independent dining). On 10/26/22, there was a diet order for Regular texture. Regular/thin liquids consistency, finger foods for independent dining. The most recent diet order was 11/04/22 which was the same as previous. On 10/13/22, there was an order for speech therapy to provide skilled dysphagia treatment (R13.12) 5 times a week for 4 weeks to analyze/modify diet/liquids levels as tolerated, establish safe swallowing protocol with compensatory safe swallowing strategies and patient/caregiver education as needed. The most recent comprehensive assessment for Resident #82 was a Significant Change reassessment Minimum Data Set (MDS), with an Assessment Review Date (ARD) of 10/17/22. This assessment found that the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had no cognitive impairment. The resident also had no signs of delirium. The Significant Change reassessment coded Resident #82 as requiring supervision with eating with set up only and identified that the resident had coughing or choking during meals or when swallowing medications. His height was 75, and he weighed 221 lbs and he had no weight loss or gain or it was unknown. The most recent MDS assessment for Resident #82 was a Quarterly assessment ARD of 1/12/23. This (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105879 If continuation sheet Page 2 of 10 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 03/30/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few assessment found that the resident had a BIMS score of 15, which indicated the resident had no cognitive impairment. The resident also had no signs of delirium. The Quarterly MDS coded Resident #82 as requiring supervision with eating with set up only and no swallowing problems. His height was 75, and he weighed 214 lbs and he had no weight loss or gain or it was unknown. Although there was a nutrition care plan and a care plan for the functional abilities for Resident #82, there was no information included in the comprehensive care plan to address the resident's swallowing problems, except for the resident's diet. According to the print medical record for Resident #82, the resident had a fiberoptic endoscopic evaluation of swallowing (FEES) on 10/26/22. The Speech Language Pathologist (SLP) recommended thin liquids via cup edge and avoid drinking straws. Continue Speech Therapy services to address weak tongue base retraction during swallowing of foods. The recommendation to avoid drinking straws was not included in the resident's comprehensive care plan. Resident #82 had Speech Therapy from 10/13/22 to 12/6/22. The SLP's discharge recommendations were Regular diet, thin liquids; compensatory strategies/position - to facility safety and efficiency, it is recommended the patient use the following strategies during oral intake: bolus size modifications and hard throat clear/reswallow, along with upright posture during meals. These recommendations were not included in the resident's comprehensive care plan. Interview with the first floor Assistant Director of Nursing (ADON) on 3/30/23 at 10:55 AM revealed that Resident #82 was on a regular diet. She stated she was not sure the resident had a swallowing problem, but stated he did have dysphagia as a diagnosis. The ADON stated that the resident received speech therapy, but was not able to access the speech therapy notes in the electronic record at that time. She recalled that Resident #82 was seated in his wheelchair at a 90 degree angle. Interview with Registered Nurse, Staff A, on 3/30/23 at 11:06 AM, who was the first nurse to respond to the resident when he had his choking incident on 2/101/23, revealed that she did not remember the resident's diet but knew he had Parkinson's and was followed by speech therapy. She said she was not aware of the resident's compensatory strategies for swallowing, as she did not work on the unit that resident live on. Interview on 03/30/23 at 11:15 AM with RN Staff B, who worked on the unit that Resident #82 lived on, revealed that she knew that resident #82 had a Regular diet, thin liquids. She did not observe any swallowing problems with the resident. She didn't observe any coughing when he swallowed. He took his meds whole and had no problems with swallowing meds. He took the meds with a cup and drank with a straw. RN Staff B did not remember Resident #82 having speech therapy. She said that Resident #82 had stiffness or rigidity with his Parkinson's disease rather than tremors. Interview with the Therapy Manager on 3/30/23 at 11:22 AM revealed that therapy was working with Resident #82 using a slow flow cup, but he refused to use it. He would have used the slow flow cup instead of using straws. She stated that he should not have used straws to drink with. The Therapy Manager stated Resident #82 had rigidity with his Parkinson's disease and they kept him on restorative physical therapy for mobility. When asked how therapy communicated their recommendations to other staff and how these recommendations are included in the care plan, she replied that they write a diet order and a care plan to give MDS staff. Therapy also inservices the staff on their recommendations. She said that Resident #82 was excellent with consistent staff support. The Therapy Manager stated she would try to find documentation for the staff training for Resident #82. The facility did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105879 If continuation sheet Page 3 of 10 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 03/30/2023 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 0656 provide this documentation during the remainder of the survey. Level of Harm - Minimal harm or potential for actual harm A Health Status note written by the first floor ADON on 2/10/23 documented the following: At approximately 12:20 p.m., nursing staff called writer to the dining room. Observed resident sitting upright at 90 degrees in his high back wheelchair and appeared to be choking. Resident was awake, moving arms, noted face was a gray color. Nursing staff [RN and CNA] was in process of performing Heimlich, thrusts from the front. Writer attempted Heimlich thrust from behind res. Nursing quickly moved resident into hallway; instructed RN to call 911. Nursing continued with thrusts from front and behind resident. [The Medical Director] was present and guided nursing during the process. Writer went to retrieve crash cart, suctioning setup and floor RN initiated. Resident was able to expel 2 small food particles. Pulse was checked and faint. Res eventually lost consciousness during the procedure. Thrusts continued until EMS arrived - resident unable to recover and expired at 12:28 PM as pronounced by [Medical Director]. Writer made several attempts to call wife and eventually reach her at approximately 1:25 PM. Resident's [wife] did not have any questions . Medical examiner picked up res remains at approximately 2:20 PM. Residents Affected - Few On 3/30/23 at 10:44 AM, during discussion of the facility's investigation of the choking incident, the Administration was informed about the resident's comprehensive care plan lacking the resident dysphagia interventions as recommended by the SLP. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105879 If continuation sheet Page 4 of 10 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 03/30/2023 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 0675 Honor each resident's preferences, choices, values and beliefs. Level of Harm - Minimal harm or potential for actual harm n observation and interview, the facility failed to ensure 3 residents (#6, #30, and #38) out of 11 to 17 residents eating in the first floor dining room during three different meals, were positioned to maximize eating abilities. Residents Affected - Few Findings: On 3/27/23 at 11:52 AM in the first floor main dining room during the lunch meal, Resident #6 was sitting in a wheelchair at a table and the table was too high. The table top was level with her neck. She was sitting at a table that was lined up with two other tables. On 3/27/23 at 11:53 AM, Resident #30, who was sitting in a wheelchair, was also seated at a table table that was too high for her. The table top was level to her neck. During the breakfast meal observation on 3/28/23 at 8:13 AM in the first floor dining room, Resident #6 was observed sitting at a table that was too high for her. She was sitting in a wheelchair and the table top was level with neck. She was sitting at a table lined up with two other tables. Resident #30 was also sitting at a table too high for her. She was sitting in a wheelchair and the table top was level with neck. Resident #30 was sitting at a different table diagonally across from Resident #6. A written policy on dining room meal service was requested; however the facility did not provide a policy regarding resident positioning during meals. During the lunch observation on 3/29/23 at 11:49 AM, in the first floor dining room, Resident #38 was sitting at a table that was too high for her. She was seated in a wheelchair and the table top was level to her upper chest. Resident #38 was sitting at a long table with five other female residents and she faced the north east side of the building. On 3/30/23 at 12:38 PM, during a discussion with the Dining Services Director, he was informed about the residents who were seated at tables that were too high for them. He stated that he did not think the height of the tables was adjustable and that he would find out. This information was not provided during the remainder of the survey. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105879 If continuation sheet Page 5 of 10 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 03/30/2023 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 - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and policy and quality assurance audits, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety, based on the following: - Clean equipment was not stored in a manner to protect it from contamination. - The dish machine hot water pressure gauge was not reaching 20 PSI (Pounds per Square Inch) pressure, as required, to ensure multi-use equipment was properly washed and sanitized. - Bulk ready-to eat, non-Time/Temperature Control for Safety (TCS) food was not properly labeled to its identity. - Employees were using beverage containers in the kitchen that were not designed to be handled to prevent contamination of the employee's hands and container. - Cold and hot TCS foods were not held at proper temperatures (41 degrees Fahrenheit or less/135 degrees Fahrenheit or more, respectively). - Refrigerated ready-to eat TCS food was not date-marked to indicate when the date the food must be consumed or discarded. These practices have a potential to affect 77 out of 79 resident who consume the facility's meals. Findings: During a follow-up visit observation to the main food production kitchen on 3/29/23 at 10:14 AM with the Dining Service Director, the facility Registered Dietitian, and the Clinical Nutrition Supervisor, the black wall mounted circular fan in the dish room had dust buildup on the cage. The Clinical Nutrition Supervisor said it was cleaned every Tuesday (3/28/23). Photographic evidence obtained. At 10:27 AM, the high temperature dish machine hot water pressure gauge only reached 10 PSI (Pounds per Square Inch), not 20 PSI, according to the dish machine data plate. The Dining Service Director tried to see if the digital console on the dish machine displayed the water pressure, but he could not determine that. At 10:41 AM, there was a 22 quart container that had approximately 10 quarts of white powder and the container was not labeled to its identity. The Dining Service Director found out from one of the Food and Nutrition Services staff that the white powder was corn starch. The Dining Service Director applied a new label to the container. Photographic evidence obtained. At 10:50 AM, there were 3 water beverage containers of water bottles with lids stored on the bottom shelf next to the clean cutting boards in a rack. These bottles were not closed beverage containers designed to be handled to prevent contamination of the employee's hands and container. Photographic evidence obtained. On 3/29/23 at 11:43 AM, the meal tray service was in progress for the first floor satellite (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105879 If continuation sheet Page 6 of 10 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 03/30/2023 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 - Many kitchen. The surveyor took the holding temperatures of cold ready-to-eat desserts with the facility's digital thermometer and found an individual slice of custard pie was 48.5 degrees Fahrenheit and individual slice of coconut cream pies was 49.6 degrees Fahrenheit. None of the individual portions of coconut pie and custard pie were held on a cooling device or ice. Photographic evidence obtained. At 11:46 PM, a 5 pound opened container of cottage cheese stored in the reach-in refrigerator unit in the first floor satellite kitchen, that was about half full was not date-marked with the date it must be used by. Photographic evidence obtained. The Dining Services Supervisor was present at the time and was informed of the temperatures and the lack of date-marking on the cottage cheese. She removed the cottage cheese. On 3/29/23 at 12:02 PM, the meal tray service was in progress for the second floor satellite kitchen. The surveyor took the holding temperatures of cold ready-to-eat dessert with the facility's digital thermometer and found an individual slice of custard pie was 49.5 degrees Fahrenheit. None of the individual portions of custard pie were held on a cooling device or ice. Photographic evidence obtained. At 12:07 PM, the surveyor took the holding temperature of the fish fillets that were held on the heat source with the facility's digital thermometer and found the fish to be 116.4 degrees Fahrenheit. The fish fillets were piled up on each other. Photographic evidence obtained. The Dining Services Supervisor and facility Registered Dietitian were present at the time and were informed of the food holding temperatures. On 3/30/2023 at 9:41, the Dining Services Director brought documentation of an inservice dated 3/29/23 on proper temps for cold food and proper procedures for cooking cold food, labeling and dating foods. Nine staff attended the training. He was asked if they had done any staff training prior to the survey and he said he would bring this information . He was asked if he did any sanitation audits and meal quality audits. He said they do an audit once a month and this is reported to the quality committee. If there is a tag or score under 90 on the audit they would do a remedial plan . On 3/30/23 at 12:08 PM, an interview with the Dining Services Director revealed the cleaning schedule for dish area was every Tuesday, but the wall fan was not included on it. The cleaning schedule showed that a Dining Tech II cleaned the fan on Wednesday, 03/29/23. The Dining Service Director provided documentation of past staff inservices - one on 2/1/23 regarding temperatures. Thirteen staff attended this inservice who were the Dining Techs that served in the Health Center. There was a staff inservice on 1/18/23 on Handwashing, Hairnets, Labeling and Dating. Twelve Health Center Dining Techs attended this inservice. The Dining Services Director provided documentation of a resident tray assessment done on 1/24/23 at lunch for regular diet on first floor. He provided monthly Nursing Care Quality Dining Reviews (audits) completed on 12/19/22, 1/17/23, 2/22/23 for the first floor and second floor satellite kitchens. This review included old F tag numbers (for nursing home regulations). These audits included hot food held at minimum 135 F and cold food held at minimum 41 F; food once opened is sealed/labeled. No issues were found in these areas. On 3/30/23 at 12:24 PM, the surveyor discussed the food safety concerns with the Dining Services Director. The Dining Services Director stated that he put a service call into the service repair (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105879 If continuation sheet Page 7 of 10 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 03/30/2023 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 company for the dish machine pressure gauge. Level of Harm - Minimal harm or potential for actual harm The Dining Services Director provided Kitchen Sanitation Review audits (main food production kitchen) completed 12/19/22, 11/22/22, 01/17/23; and 2/22/23. These audits did not address the hot water pressure gauge and other issues identified in the kitchen. Residents Affected - Many On 3/30/23 at 4:20 PM, the Dining Services Director stated he called the company responsible for servicing the dish machine and they will come out tomorrow (3/31/23) to replace the pressure gauge. He also said the digital console on the dish machine did not display the water pressure. The facility policy titled, Dish Machine & Pot Machine Procedures and Training, initiated 11/06, revised 02/09 did not include any information about hot water pressure gauge. The facility policy on Labeling Foods - Cover, Label and Date Food; Cold/Hot Food Holding without Temperature control; dented cans and returnables & Manufacture code dates; take out food and room service . safe food labeling, created 6/05, revised 6/07; 3/09; and 9/14, included the following: Opened food items are required to be covered, labeled, and dated with the date of opening and expiration after opening and person's initials. Cold food can be held without temperature control for up to 2 hours if: it was held at 41 degrees F [Fahrenheit] or lower prior to removing it from refrigeration and you can prove it though documentation. Hot food can be held without temperature control for up to 2 hours if: IT was at 140 F or higher prior to removing it from temperature control and you can prove it through documentation. K. Labels or sheets should contain the minimum information: How to store leftovers, label with a use-by time and/or use-by date, and reheating and service instructions, hot holding and cold holding temps. Consider providing food safety guidelines and warnings regarding the mishandling of food for presidents, guests, and employees. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105879 If continuation sheet Page 8 of 10 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 03/30/2023 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to dispose of the garbage properly in the facility compactor. The facility compactor was used for the entire campus. Residents Affected - Many Findings: A follow up visit to the kitchen was done on 3/29/23 at 10:55 AM with the Dining Service Director, the facility Registered Dietitian, and the Clinical Nutrition Supervisor. A pile of bagged garbage was noted in the dumpster in front of the compactor (transport bin) and the garbage storage bin was not closed or covered. Additionally, there was an open bin of the compactor that had a pile of bagged garbage that was not covered. The surveyor asked the Dining Service Director how often the compactor was operated and he did not know. There were flies flying around the compactor. Photos taken. On 03/29/23 at 10:57 AM, a letter-sized paper between the compactor and the attached dumpster was observed. The paper appeared to be a resident list. Photographic evidence taken. On 03/30/23 at 12:24 PM, the Dining Service Director stated that he talked to maintenance and the employees were supposed to use the compactor as soon as they put trash in it and he did an inservice to the staff about this. He also said they turned the dumpster (transport bin) in front of the compactor around so now the lids were closed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105879 If continuation sheet Page 9 of 10 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 03/30/2023 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, staff failed to perform proper hand hygiene during two meals observed in the first floor dining area. Staff failure to do proper hand hygiene has a potential to spread infection to the 11 to 17 residents who ate meals in the first floor dining area. Residents Affected - Some Findings: During the lunch observation on 3/27/23 from 11:44 AM to 12:07 PM, none of the five staff assisting with the meal service performed hand hygiene during that time. These staff were involved with serving resident's food, removing soiled trays, and assisting with feeding residents. During a follow-up meal observation on 3/28/23 at 7:39 AM at breakfast, there were initially three staff who were serving meals and none of them performed hand hygiene. They served trays and one of the staff used a pen to write a resident's menu selection. At 3/28/23 at 7:58 AM, one staff got a banana for a resident and did not perform hand hygiene before or after this task. At 3/28/23 at 7:59 AM, CNA, Staff C fed a resident and left to serve another meal tray. There is a stand hand sanitizer dispenser near one of the entrances located near the serving line and a hand washing sink located at the northeast part of the dining room. Physical Therapist Assistant, Staff D served resident #16 at 8:03 AM and did not perform hand hygiene before or after serving. Dining Services Supervisor washed her hands in the satellite kitchen sink after assisting with the serving line and trays. Also at this time, CNA, Staff C sat down to feed Resident #18, and did not perform hand hygiene before and after. On 03/28/23 at 8:08 AM, all 11 residents who were eating in the dining room had their plates on the serving trays. CNA Staff C finished feeding resident #18 at 8:09 AM and then bused his plate. She did not perform any hand hygiene after that or before next task touching packaged food and assembling trays. None of the 4 staff present in the dining room performed hand hygiene. At 8:17 AM, there were 4 staff in the process of assembling meal trays and none of them performed hand hygiene. At 8:23 AM CNA, Staff C left the dining room with tray cart. She did not perform any hand hygiene. On 03/30/23 at 12:38 PM, these findings were discussed with the Dining Services Director. The Dining Service Director provided Nursing Care Quality Dining Review audits dated 12/19/22, 1/17/23, and 2/22/23 of the first floor kitchen/dining room, which included, indicators for frequent hand washing observed per standards and team washing/sanitizing between resident contact. These indicators received a satisfactory score except for frequent hand washing observed per standards during the 1/17/23 and 2/22/23 audits, in which this was scored unsatisfactory and needs improvement. On 3/30/23 at 4:06 PM, the Administrator discussed if hand hygiene was addressed in Quality Assurance and Performance Improvement program and he stated the Director of Nursing does hand hygiene audits in general, but not specific to dining, and the staff have been doing hand hygiene. The surveyor discussed the staff hand hygiene findings with the Administrator. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105879 If continuation sheet Page 10 of 10