Inspection·May 19, 2023

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of the facility's Abuse, Neglect and Exploitation Policy, revised 04/22, read, It is the policy of this facility to provide protections for the health, welfare and rights of each resident . that prohibit and prevent . neglect . Definitions: . Neglect means failure of the facility, its employees . to provide goods and services to a resident that are necessary to prevent physical harm . Review of the Health Status Note dated [DATE] at 4:46 AM by LPN A read, At 4:46 AM, called to resident's room by CNA, observed resident to be unresponsive and assessed resident, blood pressure, heart rate, and respirations. At 4:47 AM, notified Supervisor resident was unresponsive. At 4:49 AM, checked resident chart for code status, resident is a full code. At 4:51 AM, notified Supervisor of resident's status is full code. At 4:54 AM, went for crash cart on the [NAME] unit. At 4:55 AM, was stopped in the hallway by the Supervisor with the crash cart. Per Supervisor, She is already gone. Law Enforcement and Emergency Medical Services (EMS). EMS implemented CPR. Review of a Health Status Note dated [DATE] at 9 AM, by RN Supervisor B read, At 4:46 AM, the CNA called LPN A to the resident's room. The resident was unresponsive. I was called by LPN A to the room. I called 911 at about 4:50 AM. The EMT's arrived but were not able to revive the resident. Law Enforcement was also on the unit. The Advanced Registered Nurse Practitioner (ARNP) was notified about the above issue. The ARNP also spoke to Law Enforcement over the phone to review the case. Attempted to reach both of resident #1's family members - no answer. Left messages on both contacts' voicemails. The Director of Nursing (DON) and Administrator were notified. On [DATE] at 11:50 AM, an interview was conducted with the Administrator and DON. The DON explained she was made aware of this incident on [DATE]. She acknowledged the resident with full code orders was found unresponsive without vital signs and CPR was not provided by the two nurses, LPN A and RN B. This is not in compliance with the facility's Abuse, Neglect and Exploitation Policy. The DON explained as part of the facility's investigation, statements were obtained and interviews were conducted with LPN A, RN Supervisor B, and CNA C. A timeline of events presented by the DON revealed that on [DATE] at approximately 4:40 AM, resident #1's assigned CNA C found the resident unresponsive. At 4:46 AM, CNA C notified the assigned LPN A. At 4:47 AM, LPN A assessed that the resident was unresponsive with no heart rate and no respirations. At 4:49 AM, LPN A checked resident #1's medical record and identified she had an order for Full Code. At 4:51 AM, LPN A notified the RN Supervisor B of resident #1's status. At 4:54 AM, LPN A retrieved the crash cart to bring to resident #1's room. At 4:55 AM, the LPN was stopped by RN Supervisor B while attempting to bring the crash cart into the resident's room and told the resident was already gone. At 5:06 AM, LPN A again notified RN Supervisor B the resident was a Full Code and CPR needed to be started. RN Supervisor B told the LPN, the resident was gone. At 5:26 AM, the Assistant Director of Nursing, (ADON) D was called by phone by LPN A and was instructed to over-ride RN Supervisor B and to begin CPR. According to the facility's timeline, life saving efforts (CPR) had not been provided to resident #1 for approximately 50 minutes and resident #1 died. The DON and Administrator stated the route cause analysis had determined the incident occurred because both nurses had not provided CPR in accordance with resident's wishes, physician's order and the facility's abuse and neglect policy. On [DATE] at 11:50 AM, during a telephone interview, the Advance Practice Registered Nurse (APRN) E recalled she was covering for resident #1's physician on [DATE] when she received a call from the facility at about 5:10 AM. She said she was informed by a nurse whose name she could not recall that resident #1 had died and was not provided CPR per her Full Code order. NP E explained that advanced directive had been discussed with resident #1's family and they made the decision for Full Code. NP (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 05/19/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety E stated, It was a poor decision for the nurses not to provide CPR to a resident who was a Full Code. She should have had CPR performed when she was found unresponsive. On [DATE] at 11:30 AM, during a telephone interview, the facility's Medical Director stated he was made aware of that resident #1 had not received CPR despite orders for full code. He added, resident #1 should have received CPR when she was found unresponsive. Residents Affected - Few On [DATE] at 12 PM, during a telephone interview, LPN A revealed she was assigned to resident #1 on [DATE] on the 11:00 PM-7:00 AM shift. She recalled at approximately 4:40 AM, she returned from break and CNA C informed her the resident was not responding. LPN A said she immediately went to the resident's room and checked her blood pressure, heart rate and respirations which were absent. She remembered she yelled out for help then obtained resident #1's medical record that noted she was a Full Code. She said, this meant you are to perform CPR. She indicated she told the RN Supervisor B that resident #1 was unresponsive and she was a Full Code. She stated she retrieved the crash cart and as she neared the resident's room, RN Supervisor B stopped her and said, she is already gone. LPN A said she again told the RN Supervisor B the resident was a full code and they needed to do CPR. She recalled RN B was standing in the doorway to the resident's room, put her hand up as if to stop her from entering the room and again stated, she is already gone. LPN A said she called the Assistant Director of Nursing (ADON) by phone to explain the situation and was told me to override the RN Supervisor B and start CPR. When I returned to the room I saw Law Enforcement in the room and it was too late for me to start CPR. LPN A said she knew the resident was a full code and CPR should have been started but as an LPN, she took directions from the RN. I should have started CPR and I didn't. On [DATE] at 12:35 PM, during a telephone interview, RN Supervisor B revealed she was the Nursing Supervisor working on the 11:00 PM-7:00 AM shift on [DATE]. She recalled on [DATE], she covered for LPN A when she went on break. She said as LPN A returned to the unit, CNA C informed the LPN that resident #1 was unresponsive. She remembered LPN A immediately went to the resident's room and informed her the resident was unresponsive and was a Full Code. I was at the unit nurses station at the time and checked the medical record and verified that CPR was to be initiated. I went to the resident's room and the resident did not have pulse or respirations. I then left the room, called 911 and remained at the nurses station to get the paperwork ready for the resident's transfer to the hospital. Law Enforcement and EMS arrived at the facility and were in the resident's room but I did not know if she could be revived. I know I should have been in the room doing CPR or instructed LPN A to begin CPR but I did not do it. RN Supervisor B spoke about why she did not initiate CPR as she should have. She said she did not want the resident to die but she knew how much she had been suffering. She used to be a feisty lady. She said she knew they would have to do chest compressions and possibly fracture some ribs. The RN Supervisor said she had not participated in a CPR drill while working at the facility. On [DATE] at 8:30 PM, during a telephone interview with resident #1's family, the son-in-law stated that Law Enforcement came to their home and gave them a telephone number to call. He said when he called the facility he spoke to the ADON and was told that his mother in law had died on [DATE] at 4:56 AM. I was told the RN had found her dead and EMS was in the facility to pronounce her death. The son-in-law explained that even though she was [AGE] years old, they wanted her to be resuscitated. We wanted everything done like CPR and being sent to the hospital. The facility never explained to us what actually happened on [DATE]. We are very upset about her death. Review of LPN A's employment record revealed she had completed Basic Life Support (BLS) training through the American Heart Association on [DATE]. Review of the facility's computerized education (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 05/19/2023 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few tracking program revealed completion of Advance Directive training on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], Recognizing/Reporting and Preventing Abuse most recently on [DATE] and Protecting Resident's Rights on [DATE]. An RN/LPN Competency Exam-was completed on [DATE] and included Palliative Care and Advanced Directives, Abuse/Neglect/Misappropriation and Resident's Rights and Responsibilities. Review of RN Supervisor B's employment record revealed she had completed BLS training through the American Heart Association on [DATE]. Review of the facility's computerized education tracking program revealed completion of Advance Directives on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], and [DATE], Preventing/Recognizing and Reporting Resident Abuse most recently on [DATE] and Residents' Rights most recently on [DATE]. An RN/LPN Competency Exam-was completed on [DATE] and included Palliative Care and Advanced Directives, Abuse/Neglect/Misappropriation and Resident's Rights and Responsibilities. Review of the Facility Assessment, dated [DATE], revealed the facility's provided care and services based on residents' needs and on-going training to ensure nursing staff were competent to identify changes in condition and problems in need of medical interventions. Education and training focuses on residents' rights and responsibility of the facility to properly care for the residents. Person centered care includes care planning and documentation of resident treatment preferences, end-of-life care, and advanced care planning. Review of the immediate actions to remove the Immediate Jeopardy implemented by the facility as stated in their accepted Immediate Jeopardy Removal Plan revealed the following, which were verified by the surveyor: An audits of all residents' paper chart and electronic medical record (EMR) was completed to ensure physician order for advance directives were correct with 100% compliance. All 7 Assistant Directors of Nursing (ADON) and Nursing Supervisors were immediately educated and conducted a hands on tabletop exercise on performing CPR, advanced directives, code status and responding to a code. Education sign in forms reviewed with 100%of licensed nurses signatures. All licensed nurses had current CPR Certification. As of [DATE], 22 of the 23 licensed nurses had completed education per review of sign in forms on CPR, Code Status and Response, and Abuse/Neglect Policy and Procedure. 1 licensed nurse was out of the state and will be educated prior to working her shift. As of [DATE], 19 of the 23 working licensed nurses had completed the ongoing mock code drills on all 3 shifts per review of signatures on the forms. 1 nurse scheduled on the 11:00 PM-7:00 AM shift will participate in the mock code drill prior to working her shift and 1 licensed nurse was out of the state and will participate in a mock code drill prior to working her shift. Review of the CPR and Advanced Directive Policy's revealed they had been reviewed by the Administrator and DON with no changes required. On [DATE], [DATE] and [DATE], Ad Hoc Quality Assessment and Performance Improvement (QAPI) meetings were conducted with the Administrator, DON, Regional Health Services Director and Medical Director to review the facility's investigation and action plans. The Medical Director was in agreement with (continued on next page) 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 05/19/2023 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 0600 the facility's plan with no recommendations. Level of Harm - Immediate jeopardy to resident health or safety Staff interviews conducted on [DATE]-[DATE] with 7 licensed staff (5 RNs and 2 LPNs) revealed all 7 nurses were knowledgeable regarding the facility's Advanced Directive Policy, CPR Policy and all 7 nurses had participated in mock code drills. All 7 nurses had current CPR Certification. Residents Affected - Few 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 05/19/2023 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to honor resident's wishes and follow the physician's order to provide basic life support and initiate Cardiopulmonary Resuscitation (CPR) for 1 of 6 residents reviewed for advanced directives (#1). On [DATE] at approximately 4:40 AM, resident #1 was found unresponsive in bed with no vital signs by Certified Nursing Assistant (CNA) C. The CNA notified Licensed Practical Nurse (LPN) A who evaluated the resident with no vital signs. LPN A informed the Registered Nurse (RN) Supervisor B as the resident had physician's order for Full Code or full resuscitation status. The RN Supervisor disregarded the Full Code order, instructed LPN A not to do anything and called Emergency Medical Services (911). The facility's failure to ensure staff followed the resident's wishes and physician's order to initiate CPR resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was removed on [DATE] and the scope and severity of the deficiencies were decreased to D, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings: Cross Reference F600 Resident #1, a [AGE] year-old long-term care resident was admitted to the facility on [DATE]. Her diagnoses included Dementia, Peripheral Vascular Disease (PVD), Cancer of Rectum, Nutritional Anemia, Chronic Obstructive Pulmonary Disease (COPD), Protein-Calorie Malnutrition, Congestive Heart Failure (CHF), Atrial Fibrillation (irregular heartbeat), Major Depressive Disorder, Chronic Kidney Disease Stage 3, Pain, and Osteoarthritis. Review of resident #1's medical record revealed a physician's order dated [DATE] for Full Code. The significant change Minimum Data Set assessment with assessment reference date of [DATE] noted she had severe cognitive impairment and required extensive assistance with her Activities of Daily Living (ADLs). Review of the resident's care plan for Advanced Directive read, The resident is a Full Code per family with the goal the resident's advanced directives wishes will be known. Review of the facility's Resident' Rights Regarding Treatment and Advanced Directives Policy and Procedure, dated 04/22, read, It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advanced directive. 9. Any decision making regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care . Review of the facility's Cardiopulmonary Resuscitation (CPR) Policy and Procedure, dated 04/22, read, It is the policy of this facility to adhere to residents' right to formulate advance directives. In accordance to these rights, this facility will implement guidelines regarding cardiopulmonary (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 05/19/2023 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few resuscitation (CPR). Policy Explanation and Compliance Guidelines: . 2. If a resident experiences a cardiac arrest, facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and : a. In accordance with the resident's advanced directive . 3. CPR certified staff will be available at all times. 4. Staff will maintain current CPR certification for healthcare providers . Review of the Health Status Note dated [DATE] at 4:46 AM by LPN A read, At 4:46 AM, called to residents room by CNA, observed resident to be unresponsive and assessed resident, blood pressure, heart rate, and respirations. At 4:47 AM, notified Supervisor resident was unresponsive. At 4:49 AM, checked resident chart for code status, resident is a full code. At 4:51 AM, notified Supervisor of resident's status is Full Code. At 4:54 AM, went for crash cart on the [NAME] unit. At 4:55 AM, was stopped in the hallway by the Supervisor with the crash cart. Per Supervisor, She is already gone. Law Enforcement and Emergency Medical Services (EMS). EMS implemented CPR. Review of a Health Status Note dated [DATE] at 9 AM, by RN Supervisor B read, At 4:46 AM, the CNA called LPN A to the resident's room. The resident was unresponsive. I was called by LPN A to the room. I called 911 at about 4:50 AM. The EMT's arrived but were not able to revive the resident. Law Enforcement was also on the unit. The Advanced Registered Nurse Practitioner (ARNP) was notified about the above issue. The ARNP also spoke to Law Enforcement over the phone to review the case. Attempted to reach both of resident #1's family members - no answer. Left messages on both contacts voicemail's. The Director of Nursing (DON) and Administrator were notified. Review of the facility's Licensed Practical Nurse Job Description, revised 05/12, read, . Job Summary: Provide direct nursing care to the residents and supervise day-to-day nursing activities performed by nursing assistants in accordance with state and federal standards . Essential Job Functions: . 2. Implement resident care based on physician orders, evaluate care and communicate with doctors for updates of orders . Essential Qualifications: Education: . Must be CPR Certified . Review of the facility's RN Supervisor Job Description, revised 12/18, read, . Provide direct nursing care to the residents and supervise day-to-day nursing activities performed by nursing assistants and staff nurse in accordance with state and federal standards. This supervision may be required by the DON to ensure that the highest degree of quality care is maintained at all times . Role/Responsibility Supervisor - Nights, Daily Duties: Oversee care of all residents and intervene appropriately . Essential Qualifications: Education: . Must be CPR Certified . On [DATE] at 11:50 AM, an interview was conducted with the Administrator and DON. The DON explained she was made aware of this incident on [DATE]. She acknowledged the resident with full code orders was found unresponsive without vital signs and CPR was not provided by the two nurses, LPN A and RN B. She stated, this is not in compliance with the facility's Resident's Rights Policy, Advanced Directive Policy, and CPR Policy. The DON explained as part of the facility's investigation, statements were obtained and interviews were conducted with LPN A, RN Supervisor B, and CNA C. A timeline of events presented by the DON revealed that on [DATE] at approximately 4:40 AM, resident #1's assigned CNA C found the resident unresponsive. At 4:46 AM, CNA C notified the assigned LPN A. At 4:47 AM, LPN A assessed that the resident was unresponsive with no heart rate and no respirations. At 4:49 AM, LPN A checked resident #1's medical record and identified she had an order for Full Code. At 4:51 AM, LPN A notified the RN Supervisor B of resident #1's status. At 4:54 AM, LPN A retrieved the crash cart to bring to resident #1's room. At 4:55 AM, the LPN was stopped by RN Supervisor B while attempting to bring the crash cart into the resident's room and told the resident was (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 05/19/2023 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few already gone. At 5:06 AM, LPN A again notified RN Supervisor B the resident was a Full Code and CPR needed to be started. RN Supervisor B told the LPN, the resident was gone. At 5:26 AM, the Assistant Director of Nursing (ADON) D was called by phone by LPN A and was instructed to over-ride RN Supervisor B and to begin CPR. According to the facility's timeline, life saving efforts (CPR) had not been provided to resident #1 for approximately 50 minutes and resident #1 died. The DON and Administrator stated the route cause analysis had determined the incident occurred because both nurses had not provided CPR in accordance with resident's wishes and physician order for full code. On [DATE] at 11:50 AM, during a telephone interview, the Advance Practice Registered Nurse (APRN) E recalled she was covering for resident #1's physician on [DATE] when she received a call from the facility at about 5:10 AM. She said she was informed by a nurse whose name she could not recall that resident #1 had died and was not provided CPR per her Full Code order. NP E explained that advanced directive had been discussed with resident #1's family and they made the decision for Full Code. NP E stated, It was a poor decision for the nurses not to provide CPR to a resident who was a Full Code. She should have had CPR performed when she was found unresponsive. On [DATE] at 11:30 AM, during a telephone interview, the facility's Medical Director stated he was made aware of that resident #1 had not received CPR despite orders for full code. He added, resident #1 should have received CPR when she was found unresponsive. On [DATE] at 12:00 PM, during a telephone interview, LPN A revealed she was assigned to resident #1 on [DATE] on the 11:00 PM-7:00 AM shift. She recalled at approximately 4:40 AM, she returned from break and CNA C informed her the resident was not responding. LPN A said she immediately went to the resident's room and checked her blood pressure, heart rate and respirations which were absent. She remembered she yelled out for help then obtained resident #1's medical record that noted she was a Full Code. She said, this meant you are to perform CPR. She indicated she told the RN Supervisor B that resident #1 was unresponsive and she was a Full Code. She stated she retrieved the crash cart and as she neared the resident's room, RN Supervisor B stopped her and said, she is already gone. LPN A said she again told the RN Supervisor B the resident was a full code and they needed to do CPR. She recalled RN B was standing in the doorway to the resident's room, put her hand up as if to stop her from entering the room and again stated, she is already gone. LPN A said she called the Assistant Director of Nursing (ADON) by phone to explain the situation and was told me to override the RN Supervisor B and start CPR. When I returned to the room I saw Law Enforcement in the room and it was too late for me to start CPR. LPN A said she knew the resident was a full code and CPR should have been started but as an LPN, she took directions from the RN. I should have started CPR and I didn't. On [DATE] at 12:35 PM, during a telephone interview, RN Supervisor B revealed she was the Nursing Supervisor working on the 11:00 PM-7:00 AM shift on [DATE]. She recalled on [DATE], she covered for LPN A when she went on break. She said as LPN A returned to the unit, CNA C informed the LPN that resident #1 was unresponsive. She remembered LPN A immediately went to the resident's room and informed her the resident was unresponsive and was a Full Code. I was at the unit nurses station at the time and checked the medical record and verified that CPR was to be initiated. I went to the resident's room and the resident did not have pulse or respirations. I then left the room, called 911 and remained at the nurses station to get the paperwork ready for the resident's transfer to the hospital. Law Enforcement and EMS arrived at the facility and were in the resident's room but I did not know if she could be revived. I know I should have been in the room doing CPR or instructed LPN A to begin CPR but I did not do it. RN Supervisor B spoke about why she did not initiate CPR as she should have. She said she did not want the resident to die but she knew how much she had been suffering. She used to be a feisty lady. She said she knew they would have to do chest (continued on next page) 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 05/19/2023 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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few compressions and possibly fracture some ribs. The RN Supervisor said she had not participated in a CPR drill while working at the facility. Review of LPN A's employment record revealed she had completed Basic Life Support (BLS) training through the American Heart Association on [DATE]. Review of the facility's computerized education tracking program revealed completion of Advance Directive training on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], Recognizing/Reporting and Preventing Abuse most recently on [DATE] and Protecting Resident's Rights on [DATE]. An RN/LPN Competency Exam-was completed on [DATE] and included Palliative Care and Advanced Directives, Abuse/Neglect/Misappropriation and Resident's Rights and Responsibilities. The Exam had not been graded. Review of RN Supervisor B's employment record revealed she had completed BLS training through the American Heart Association on [DATE]. Review of the facility's computerized education tracking program revealed completion of Advance Directives on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], and [DATE], Preventing/Recognizing and Reporting Resident Abuse most recently on [DATE] and Residents' Rights most recently on [DATE]. An RN/LPN Competency Exam-was completed on [DATE] and included Palliative Care and Advanced Directives, Abuse/Neglect/Misappropriation and Resident's Rights and Responsibilities. The Exam had not been graded. On [DATE] at 2:10 PM, the ADON recalled LPN A had telephoned her on [DATE] at approximately 5:30 AM to inform that resident #1 had died and she was Full Code. I asked her if she initiated CPR and she said, no. I told her she should have initiated CPR and she said RN Supervisor B told her no because she was already gone. I told her to override RN Supervisor B and to initiate CPR. The ADON explained the LPN told her she knew she should have started CPR but when she went back to the resident's room, Law Enforcement were already there. She explained that if a resident was found unresponsive, the staff person should call for help, check their code status and start CPR if the resident was a full code. You delegate someone to call 911 and you do not stop CPR until EMS arrives and takes over. She added, LPN A should have started CPR for resident #1. On [DATE] at 8:30 PM, during a telephone interview with resident #1's family, the son-in-law stated that Law Enforcement came to their home and gave them a telephone number to call. He said when he called the facility he spoke to the ADON and was told that his mother in law had died on [DATE] at 4:56 AM. I was told the RN had found her dead and EMS was in the facility to pronounce her death. The son-in-law explained that even though she was [AGE] years old, they wanted her to be resuscitated. We wanted everything done like CPR and being sent to the hospital. The facility never explained to us what actually happened on [DATE]. We are very upset about her death. Review of the Facility Assessment, dated [DATE], revealed the facility's provided care and services based on residents' needs and on-going training to ensure nursing staff were competent to identify changes in condition and problems in need of medical interventions. Education and training focuses on residents' rights and responsibility of the facility to properly care for the residents. Person centered care includes care planning and documentation of resident treatment preferences, end-of-life care, and advanced care planning. Review of the immediate actions to remove the Immediate Jeopardy implemented by the facility as stated in their accepted Immediate Jeopardy Removal Plan revealed the following, which were verified by the surveyor: An audits of all residents' paper chart and electronic medical record (EMR) was completed to ensure (continued on next page) 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 05/19/2023 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 0678 physician order for advance directives were correct with 100% compliance. Level of Harm - Immediate jeopardy to resident health or safety All 7 Assistant Directors of Nursing (ADON) and Nursing Supervisors were immediately educated and conducted a hands on tabletop exercise on performing CPR, advanced directives, code status and responding to a code. Education sign in forms reviewed with 100%of licensed nurses signatures. Residents Affected - Few All licensed nurses had current CPR Certification. As of [DATE], 22 of the 23 licensed nurses had completed education per review of sign in forms on CPR, Code Status and Response, and Abuse/Neglect Policy and Procedure. 1 licensed nurse was out of the state and will be educated prior to working her shift. As of [DATE], 19 of the 23 working licensed nurses had completed the ongoing mock code drills on all 3 shifts per review of signatures on the forms. 1 nurse scheduled on the 11:00 PM-7:00 AM shift will participate in the mock code drill prior to working her shift and 1 licensed nurse was out of the state and will participate in a mock code drill prior to working her shift. Review of the CPR and Advanced Directive Policy's revealed they had been reviewed by the Administrator and DON with no changes required. On [DATE], [DATE] and [DATE], Ad Hoc Quality Assessment and Performance Improvement (QAPI) meetings were conducted with the Administrator, DON, Regional Health Services Director and Medical Director to review the facility's investigation and action plans. The Medical Director was in agreement with the facility's plan with no recommendations. Staff interviews conducted on [DATE]-[DATE] with 7 licensed staff (5 RNs and 2 LPNs) revealed all 7 nurses were knowledgeable regarding the facility's Advanced Directive Policy, CPR Policy and all 7 nurses had participated in mock code drills. All 7 nurses had current CPR Certification. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105879 If continuation sheet Page 10 of 10