Health inspection·July 1, 2021

F 0584 should have noticed spill before now. Level of Harm - Minimal harm or potential for actual harm Interview on 6/29/21 at 3:22 PM with the Housekeeping Manager revealed that at this time she has 3 housekeepers and that the housekeepers clean resident rooms everyday, which includes cleaning up spills, She reported that spills should never be there for more than a day. She reported that the housekeeper needed to scrap the spill and that she did not do her job. Residents Affected - Few 2. Review of Resident #27's record revealed that this resident was admitted to the facility on [DATE] and has diagnosis that includes Muscle wasting and atrophy, and need for assistance with personal care, and has a Brief Interview For Mental Status dated 5/6/21 with a score of 13 (Cognitively intact). Observation of Resident #27s room on 6/28/21 at 12:28 PM revealed that there was a bookcase located in the residents room to the left of her bed. It was noted that the shelf of the bookcase was broken and on the floor and that the residents belonging were lying on the floor. (Photgraphic Evidence Obtained). An interview with Resident #27 was conducted at this time and the resident reported the aides are aware of the broken bookcase and that it has been that way for about 3 weeks and no one has fixed it. Observation of Resident #27s room on 6/29/21 at 10:09 AM revealed the bookcase located in the residents room to the left of her bed, was still broken withthe shelf located on the floor and that the residents belonging were still lying on the floor. Observation on 6/29/21 at 3:00 PM of Resident #27's room revealed that the bookcase in her room was now fixed and all of her belongings were appropriately stored. Interview with Resident #27 revealed that Staff I fixed the bookcase and arranged her belongings without me even asking her to. Interview on 6/29/21 at 3:05 PM with Staff I, Certified Nursing Assistant (CNA) revealed that she did not work yesterday but worked today and was assigned to Resident #27 and found the book shelf broken with items on the floor so picked it up and fixed everything. An interview on 6/29/21 at 3:08 PM with Staff B, RN revealed the aide or anyone else could have assisted and cleaned up the resident's bookshelf and belongings on the floor. 3. Review of the facility policy titled Daily Patient Room Cleaning with a revised date of 9/05/2017 revealed the following: -B, Do quick straighten up. -C-4) Dust mop floor. Use dust mop to gather all trash and debris on floor. Sweep to the door, pick up with dust pan. -C-5) Damp mop floor with germicide solution damp mop floor working from back corner to door FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105998 If continuation sheet Page 2 of 15 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 105998 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Winter Haven 2701 Lake Alfred Rd Winter Haven, FL 33881 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, observation, and policy review the facility failed to ensure a grievance was acted upon for one resident (#46) of fifteen sampled residents. Findings included: Resident #46 was admitted to the facility with a diagnosis of perforated intestine, according to the face sheet in the admission record. A review of the Minimum Data Set (MDS) assessment in the medical record, dated 5/28/21, reflected a Brief Interview for Mental Status (BIMS) score of 14, indicating Resident #46's cognition was intact. On 6/28/21 at 10:39 AM an interview was conducted with Resident #46. She said the man that lives next door [Resident #16] is verbally abusive to the staff. He is obnoxious. He screams. He is vulgar. He wanders everywhere. She said he has not come in her room or spoke to her, but it's really a bother, and the staff aren't allowed to do anything about it. She has reported it to the ARNP [Advanced Registered Nurse Practitioner] and the DON [Director of Nursing]. Resident #46 also said that it takes thirty minutes to an hour for anyone to answer the call light on the eleven to seven shift [night shift]. They are so busy chasing that man around to keep everybody safe. Review of the complaint/grievance report, dated 6/24/21, reflected the following findings: Communicated by: Resident #46, pertaining to: Resident #16. Communicated to the SSD [Social Services Director]. Concern Resident #46 reports that Resident #16 is very disruptive at night, yelling profanities and slamming doors and is disturbing her sleep. Plan to resolve complaint/grievance: Resident offered a room change and declined. Resident made aware that ARNP would be made aware of Resident #46's behaviors. Results of action taken: SS [Social Services] and DON met with Resident #46 to discuss concern and plan to resolve concern. Resident told us to leave family room because her family was coming for a visit. Resolution Complaint/grievance resolved? Yes Will follow up as needed. Is complainant satisfied? the answers were blank (yes, no). Complainant remarks: We will see. Resident #46 encouraged to voice any other concerns that she may have. 6/25/21 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105998 If continuation sheet Page 3 of 15 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 105998 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Winter Haven 2701 Lake Alfred Rd Winter Haven, FL 33881 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 0585 Resident #16 was admitted to the facility with diagnoses of schizophrenia and bipolar disorder, according to the face sheet in the admission record. Level of Harm - Minimal harm or potential for actual harm A review of the MDS assessment dated [DATE], reflected a BIMS of 15, indicating an intact cognition. Residents Affected - Few Further review of the assessment revealed the following information: Section G, functional status, locomotion on unit was marked supervision of one person. Section E, behaviors, verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) was marked 'behavior of this type occurred daily'. Other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) was marked 'behavior of this type occurred daily'. Under 'wandering presence and frequency', the choice was marked 'behavior of this type occurred daily'. On 7/01/21 at 10:23 AM an interview was conducted with the Social Services Director (SSD), who was the grievance coordinator at the facility. She said the DON and herself met with Resident #46 in the family room. Resident #46 had concerns with Resident #16 regarding him not sleeping at night, yelling, slamming doors, and profanity, and it was keeping her awake. They offered her a room on the other unit. She did not want that. She asked what would be done. We said we would talk to the ARNP. She asked what she would do about it. We said we could not share that because it would violate privacy rights. The SSD said she let the ARNP know about the behaviors. There have been no further complaints from Resident #46. I have not heard that he isn't sleeping at night. The SSD said she did not ask Resident #46 if she is still having concerns about Resident #16. I talk to her everyday about her discharge plan and she has not voiced anything about him. On 6/30/21 at 10:33 AM an interview was conducted with Resident #16's CNA (Certified Nursing Assistant), Staff C. Staff C, CNA said Resident #16 does have behaviors. He takes all his clothes out and puts them on the bed, even the dirty ones from his basket. He puts food in the toilet and clogs it a lot. There has been no aggression on her shift. He does yell, but she has never seen him do anything to anyone else. 06/30/21 at 10:43 AM an observation was conducted. Resident #16 was walking through the hallway on the nursing unit with the use of a walker, pleasant and asking for coffee. On 6/30/21 at 10:59 AM an interview was conducted with Staff B, RN (Registered Nurse), Unit Manager. Staff B, RN said the ARNP with psychiatric services visits every Friday. She is managing Resident #16 's medications. Sometimes he refuses medications. He went to the hospital Saturday early in the morning for aggressive behavior. Normally somebody goes and talks to him, or he goes and talks to social services. On 7/01/21 at 1:18 PM a follow up interview was conducted with the DON. She said Resident #46 had a grievance and we wrote it up. We could not give her a lot of information because of HIPAA [Health Insurance Portability and Accountability Act] violation. We offered a room change, but she did not want it. She started getting upset and asked us to leave because her family was coming, and she did (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105998 If continuation sheet Page 4 of 15 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 105998 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Winter Haven 2701 Lake Alfred Rd Winter Haven, FL 33881 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 0585 Level of Harm - Minimal harm or potential for actual harm not want to be upset for the visit. We left because she asked us too; it wasn't quite resolved. She was upset that we offered her to move. She did not feel she had to move when she wasn't the problem. We tried to explain that we offer to move the person who has the concern, but that is when she asked us to leave. I have not followed up with her. The SSD usually goes back and follows up with them. We should have followed up with her. Residents Affected - Few Review of the policy, Complaint/Grievance, dated 8/9/18, revealed the following: Overview: The intent of this guideline is to support each resident's right to voice grievances (e.g., those about treatment, care, management of funds, loss clothing, or violation of rights) and to assure that after receiving a complaint/grievance, the center actively seek a resolution for resident appropriately apprised of its progress toward resolution. Prompt efforts by the center to resolve grievances the resident may have, including those with respect to the behavior of other residents. Grievances will be reviewed by the quality assurance performance improvement committee. The resident should have reasonable expectations of care and services and the center should address those expectations in a timely, reasonable, and consistent manner. Purpose To support each resident's right to voice grievances resulting in a follow up and resolution while keeping the resident apprised of its progress toward resolution. Process An employee receiving a complaint/grievance from a resident, family member and/or visitor shall initiate a complaint/grievance form or electronic equivalent. The grievance officer/designee shall act on the grievance and begin follow up of the concern or submit it to the appropriate department director for follow-up. The grievance follow-up should be completed in a reasonable timeframe; this should not exceed 14 days. The findings of the grievance shall be recorded on the complaint/grievance form or electronic equivalent. The individual voicing the grievance shall receive a follow up communication with the resolution, a copy of the grievance resolution will be provided to the resident upon request. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105998 If continuation sheet Page 5 of 15 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 105998 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Winter Haven 2701 Lake Alfred Rd Winter Haven, FL 33881 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 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and policy review the facility failed to ensure the necessary information was provided to the receiving facility during a transfer to the hospital for one resident (#16) of three residents sampled for a hospital transfer. Findings included: Resident #16 was admitted to the facility with diagnoses of schizophrenia and bipolar disorder, according to the face sheet in the admission record. A review of the Minimum Data Set (MDS) assessment dated [DATE], reflected a Brief Interview for Mental Status (BIMS) of 15, indicating an intact cognition. Further review of the assessment revealed the following information: Section G, functional status, locomotion on unit was marked supervision of one person. Section E, behaviors, verbal behavioral symptoms directed toward others (e.g. threatening others, screaming at others, cursing at others) was marked 'behavior of this type occurred daily'. Other behavioral symptoms not directed toward others (e.g. physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) was marked 'behavior of this type occurred daily'. Under 'wandering presence and frequency', the choice was marked 'behavior of this type occurred daily'. Review of a telephone order in Resident #16's record reflected a physician's order dated 5/21/21 for ABH (Ativan, Benadryl, Haldol) gel 0.5 milligrams (mg)-12.5 mg-0.5 mg, apply 1 milliliter (ml) topically [on the skin] to the neck, every 6 hours as needed for agitation. Review of a physician's order in the medical record dated 6/26/21 reflected transfer to hospital via 911 for altered mental status and aggression. Review of the nurse's notes in the Resident's medical record revealed the following findings: 6/26/21 2:38 p.m. Resident verbally aggressive, yelling and cursing throughout unit and difficult to redirect. Resident banging on windows and repeatedly slamming doors. Resident threatening staff and becoming physically aggressive towards staff. MD [medical doctor] made aware and prn (as needed) dose of Ativan administered per MD orders. Resident responsible party made aware of altered mental status and aggression. Continue to monitor. 6/26/21 3:43 p.m. Resident transferred via 911 for altered mental status and aggression towards staff for eval and treat per MD. Resident's daughter made aware. 6/26/21 10:33 p.m. Resident returned from the hospital via stretcher. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105998 If continuation sheet Page 6 of 15 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 105998 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Winter Haven 2701 Lake Alfred Rd Winter Haven, FL 33881 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 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Further review of Resident #16's record revealed there was no other information regarding Resident #16's transfer. On 7/01/21 at 10:23 AM an interview was conducted with the Social Services Director (SSD). She said, he went to the hospital on Saturday, and the doctor did more medication changes on Saturday. I was not here Saturday. The DON sent him out. On 6/30/21 at 10:59 AM an interview was conducted with Staff B, RN (Registered Nurse), Unit Manager. Staff B, RN said he went to the hospital Saturday early in the morning for aggressive behavior. The doctor gave the order. The DON called the physician, and he gave an order to send Resident #16 out for evaluation and treatment with a 911 pick-up. He was aggressive with the staff on night and morning shift. The weekend supervisor called the DON. Normally somebody goes and talks to him or he goes and talks to social services. He refused the medications. He doesn't normally have a problem with the day or night shift. On 6/30/21 at 4:20 PM an interview was conducted with the DON. She said he was getting aggressive, altered mental status. We called the doctor and he wanted him sent out. The hospital evaluated him and sent him back. He didn't come back with any new orders. He was cursing, walking up to staff aggressively. He says inappropriate words. He was being loud. I have never seen aggression toward residents, just staff. A lot of times he won't take his medications so he may not have allowed them to put it (the ABH gel) on. It is listed under 'other', which is why it is probably not showing up for them. Review of the June 2021 MAR (medication administration record) revealed that the ABH gel had never been administered. On 7/01/21 at 12:35 PM an interview was conducted with the DON, who confirmed there wasn't a transfer form in Resident #16's record. On 7/01/21 at 1:18 PM a follow up interview was conducted with the DON. She said I don't know why they didn't do the transfer form. Whether it's a [NAME] Act or not, the transfer form still should be completed. We sent him out for an evaluation. He normally walks around talking loud. That day he was louder than usual and verbally inappropriate. We tried redirecting him. He has PRNs, but once he has at a certain level he isn't going to take anything. The hospital evaluated him and sent him back. Review of the policy, Transfer/Discharge Notification and Right to Appeal, dated 3/26/18 reflected the following: Policy: Transfer and discharges of residents, initiated by the center (facility initiated) will be conducted according to Federal and/or State regulatory requirements. Procedure: The center must permit each resident to remain in the center, and not transfer or discharge the resident from the center unless: a. The transfer or discharge is necessary for the resident's welfare and the resident's needs can't be met at the center unless: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105998 If continuation sheet Page 7 of 15 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 105998 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Winter Haven 2701 Lake Alfred Rd Winter Haven, FL 33881 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 0622 b. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the center; Level of Harm - Minimal harm or potential for actual harm c. The safety of individuals in the center is endangered due to clinical or behavioral status of the resident; Residents Affected - Few d. The health of individuals in the center would otherwise be endangered; Documentation: When the center transfers or discharges a resident under any of the circumstances listed above the facility will ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider. Documentation in the medical record to include: the basis for the transfer; In case of inability to meet resident's needs (as per above); the specific needs can not be met, The facility's attempts to meet the resident's needs, And the service available at the receiving facility to meet those needs The documentation must be made by: A physician when transfer or discharge is necessary due to: The safety of individuals in the center is endangered due to clinical or behavioral status of the resident; The health of individuals in the center would otherwise be endangered. Information provided to the receiving provider must include but is not limited to: Contact information of the practitioner responsible for the care of the resident. Resident representative information including contact information Advance Directives Special care instructions or precautions for ongoing care as indicated Comprehensive care plan goals All other necessary information, including copies of the resident's discharge summary and other documentation, as applicable to ensure safe and effective transition of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105998 If continuation sheet Page 8 of 15 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 105998 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Winter Haven 2701 Lake Alfred Rd Winter Haven, FL 33881 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** Based on record review and interview the facility failed to obtain documentation from a hospice provider to ensure coordination of services for 1 of 2 (#17) residents receiving hospice services. Residents Affected - Few Findings included: Review of the facility policy titled Hospice Care with an effective date of 11/30/14, and a revision date of 9/20/17 revealed the following: To ensure continuity of care between the center and the hospice provider, the Director of Nursing will designate a clinical member of the interdisciplinary team to work with the hospice including the following: Coordination of care plan process between the hospice and the center Communication with hospice representatives, hospice medical director and the patient/residence attending physician to ensure coordination of care. Ensure the following information is obtained from the Hospice: Most recent hospice plan of care A review of the Minimum Data Set (MDS) dated [DATE] indicates that Resident #17 is currently receiving hospice care. Review of the current physician orders revealed that the resident has a current order for hospice services dated 5/14/21. A review of Resident #17's electronic record and the paper record revealed that there was no documentation in the record that would identify what disciplines or services this resident would be receiving from the hospice provider, additionally there was no hospice assessment, no hospice care plan and no hospice ongoing notes that would indicate what needs the resident had and what is actually being provided. An interview on 6/30/21 at 9:46 AM with Staff J, Licensed Practical Nurse (LPN) revealed that if there are any changes with the resident, they notify the hospice team as well as the physician. She reported that the hospice nurse probably comes in once a week but that she has not seen that person and maybe they come on a different shift. She reported the hospice notes should be in the resident chart. An interview on 6/30/21 at 2:35 PM with the Director of Nursing (DON) revealed she is not sure how often hospice comes in to provide services for Resident #17, and that she is not sure of what the residents hospice plan of care is. She reported that she did investigate and found there is no documentation in the record from hospice. She reported she is unsure as to why there is no hospice plan of care or any other hospice documentation in the record. A phone interview on 6/30/21 at 3:05 PM with Staff K, Hospice Registered Nurse (RN), reported that that there are 2 hospice nurses on this team and the other nurse works weekends and visits the facility to see this resident on the weekends. She reported per the documentation the nurse has completed all visits and has faxed documentation including the plan of care to the facility. She reported as far as she knows the facility has not reported they have not received any documentation, but they (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105998 If continuation sheet Page 9 of 15 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 105998 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Winter Haven 2701 Lake Alfred Rd Winter Haven, FL 33881 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 have requested the plan of care today. 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: 105998 If continuation sheet Page 10 of 15 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 105998 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Winter Haven 2701 Lake Alfred Rd Winter Haven, FL 33881 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and review of facility policy, the facility failed to provide care and services consistent with professional standards of practice related to communication with the dialysis facility, as evidenced by a failure of monitoring resident status pre and post dialysis for one resident (#25) of four residents receiving dialysis. Residents Affected - Few Findings included: A review of the medical record for Resident #25 revealed diagnoses that included type II diabetes, end stage renal disease, and dependence on renal dialysis, and anemia. The Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Review physician's orders revealed: -An order dated 2/23/2021 for Hemodialysis M/W/F (Monday, Wednesday, Friday) with pick up at 9:30 a.m., dialysis time 10:30 a.m. -An order dated 2/23/21 to assess dialysis port site on the left upper chest for bruising/bleeding/symptoms of infection. A review of Resident # 25's care plan dated 05/05/21 revealed a focused area for renal dialysis related to renal failure and chronic kidney disease (CKD), with interventions that included check and change dressing daily, dialysis M/W/F, monitor for signs and symptoms (s/s) infection to access site, monitor/document and report s/s peripheral edema, bleeding, hemorrhage, or sepsis. A review of the medication administration record (MAR) and treatment administration record (TAR) for February 2021 through June 2021 revealed no documentation related to checking and/or changing the dressing on the dialysis site. An interview was conducted with Resident #25 on 06/30/2021 at 9:02 a.m. Resident #25 confirmed that she receives dialysis Monday/ Wednesday/Friday (M/W/F) at an outpatient facility. Resident #25 also confirmed that she does not take a dialysis binder with her to dialysis, but that if there are any papers she needs to bring back, the dialysis staff give her an envelope to give to the staff in the nursing home. An interview was conducted on 06/30/2021 at 9:10 a.m. with the Director of Nursing (DON) who revealed because of COVID-19, some dialysis facilities stopped using the resident binder for communication, but staff should check the resident vitals prior to transport. The DON also stated if there are any changes or issues during dialysis that the nursing home would receive a call from the dialysis facility. She confirmed all communication should be documented in the resident's medical record. An interview was conducted with Staff A, Licensed Practical Nurse (LPN) on 06/30/2021 at 9:20 a.m. who stated she does take resident vital signs prior to transport for dialysis, and when the resident returns to the facility she was not aware of a dialysis binder, or a Dialysis Communication form. An interview was conducted with Staff B, Registered Nurse (RN), Unit Manager 06/30/21 at 12:20 p.m. Staff B, RN stated the nurse should be assessing the dialysis site every shift. Staff B, RN also stated that the Dialysis Communication form should be completed by the nursing staff prior to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105998 If continuation sheet Page 11 of 15 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 105998 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Winter Haven 2701 Lake Alfred Rd Winter Haven, FL 33881 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident being transported to the dialysis center, the form should be sent with the resident and facility staff should also complete the Dialysis Communication Record form on the resident's return. Staff B, RN confirmed that there was no documentation related to observation of the dialysis site in Resident #25's record. The Dialysis Communication form for 06/09/2021 was reviewed and the assessment area pre and post dialysis were not completed. No other Dialysis Communication forms were identified in Resident #25's record. A review of the facility policy titled, Coordination of Hemodialysis Services, last revised on 07/02/2019 revealed under the section titled 'Procedure': - The Dialysis Communication form will be initiated by the facility for any resident going to an End Stage Renal Disease (ESRD) center for hemodialysis. - Upon the resident's return to the facility, nursing will review the Dialysis Communication form and information completed by the dialysis center or the information sent by the dialysis center; communicate with the resident's physician and other ancillary departments as needed, implement interventions as appropriate. - Nursing will complete the post dialysis information and the Dialysis Communication form and file the form in the Resident's Clinical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105998 If continuation sheet Page 12 of 15 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 105998 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Winter Haven 2701 Lake Alfred Rd Winter Haven, FL 33881 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 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 maintain the kitchen in a safe and sanitary manner related to ensuring the range hood was free from dust. Residents Affected - Some Findings included: Observations during the initial tour of the facility's kitchen on 6/28/21 at 10:30 AM revealed that the kitchen housed a range hood which was located over the stove and steam oven. Closer observation of the range hood revealed the light covers and piping were covered in dust particles. Closer observation of the range hood revealed the sealants had become dislodged from the seams of the range hood and was noted to be blowing back and forth over the stove and steamer. (Photographic Evidence Obtained) An interview at this time with the Certified Dietary Manager (CDM), who was present in the kitchen at the time of the initial tour revealed she was unsure as to when the range hood was last cleaned. An interview on 6/28/21 at 10:42 AM with the Maintenance Director revealed the vendor who cleans the hood is due to come tomorrow. They come every 3 months and in between visits the Maintenance Director and dietary staff are responsible to keep it clean. An interview on 6/28/21 at 1:39 PM with the Maintenance Director revealed the facility does not have a contract with the range hood vendor and does not have a policy related to the range hood, or its maintenance/cleaning. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105998 If continuation sheet Page 13 of 15 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 105998 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Winter Haven 2701 Lake Alfred Rd Winter Haven, FL 33881 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview it was determined that the facility failed to provide Quality Assessment and Assurance (QAA) practice that demonstrated implementation of an effective action plan to correct the previously cited deficient practice at F584 related to providing a clean and sanitary environment for one resident (#17) out of three residents who received nutrition through enteral feeding. Findings included: A review of the facility policy titled, Performance Improvement Committee, effective 11/30/2014 and revised 8/19/2020, identified that The committee will assure QAPI activities have indicators and standards/thresholds for evaluation, that appropriate actions are implemented, and that such correction has been evaluated by subsequent monitoring. Review of the admission Record for Resident #17 revealed the resident was admitted to the facility on [DATE] with readmission on [DATE] and the diagnoses included personal history of transient ischemic attack and cerebral infarction, cerebrovascular disease, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, encounter for attention to gastrostomy and encounter for palliative care. Review of the September 2021 physician orders revealed an order ,dated 8/5/21, for Enteral Feed Order every shift for Nutrition, Enteral Tube Feeding Jevity 1.2 at 55 ml/hr (milliliters per hour) x 20 hours. An observation of Resident #17, on 9/8/21 at 9:23 a.m. revealed the resident lying in her bed with the head of her bed elevated and her enteral feed container hanging from a pole next to her bed. Inspection of the resident's room surrounding her bed revealed a puddle of a light brown substance pooled on the floor located in the area beneath the tube feed formula. In addition, there were spatters of the light brown substance extending from under the pole out approximately two feet. ( Photographic Evidence Obtained) An observation of Resident #17 on 9/8/21 at 10: 41 a.m. revealed the resident lying in her bed with the head of her bed elevated and her enteral feeding container hanging from a pole. The observation revealed the puddle of light brown substance and the spatters of the light brown substance were still present. ( Photographic Evidence Obtained) An interview was conducted on 9/8/21 at 10: 45 a.m. with a person who identified herself as a Housekeeping Manager who was assisting from another facility. She stated the facility's Housekeeping Manager was on vacation. She stated there are four housekeepers out with COVID -19 and she has other housekeepers from other places helping. She was asked if the 200 hallway rooms had been cleaned by housekeeping today. She stated that on the left side of the hallway; the rooms had been cleaned. (Resident # 17 resides in a room on the left side of the hallway.) An observation with the Housekeeping Manager on 9/8/21 at 10:45 a.m. revealed the puddle of a light brown substance and the spatters of the light brown substance were still present. She stated that the housekeeping staff who cleaned the room should have cleaned the spill. She called a staff member to come in the room. The staff member stated he was the floor tech and he had cleaned the room this (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105998 If continuation sheet Page 14 of 15 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 105998 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vivo Healthcare Winter Haven 2701 Lake Alfred Rd Winter Haven, FL 33881 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few morning. He looked at the spillage and stated that when he cleaned the room someone was over there, so he couldn't clean and he had planned to come back, and clean that side of the room. He stated he was not aware of the spillage. An interview was conducted with Staff J, Licensed Practical Nurse (LPN) on 9/8/21 at approximately 12:33 p.m. She stated she was the assigned nurse for Resident #17 for this day. She stated when she came in at 7:00 a.m. the tube feeding was hung and running. She stated she provided care for Resident #17 this morning, administered medication and ensured positioning but did not look down at the floor. She stated she was unaware of the spillage. She stated she did not know why it was on the floor and housekeeping should have cleaned it up. An interview was conducted with Staff B, Certified Nursing Assistant (CNA) on 9/8/21 at 2:17 p.m. She stated she was the assigned CNA for the day shift today for Resident #17. She stated she provided care for Resident #17 several times today but, I don't' look at the floor. She stated she did not notice the spillage. An interview was held with the Director of Nursing (DON) on 9/8/21 at 6:50 p.m. regarding the substance on the floor in Resident 17's room. She stated she heard there were some drips and housekeeping cleaned it up. She stated, Anyone can clean up the floor, and her expectation was if someone spilled something they should clean it up. Review of a policy titled, Cleaning and Disinfecting Resident's Rooms, revised August 2013, revealed: Purpose : The purpose of this procedure is to provide guidelines for cleaning and disinfecting resident's rooms. General Guidelines: 1. Housekeeping surfaces (e.g floors, tabletops) will be cleaned on a regular basis,when spills occur, and when these surfaces are visibly soiled. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105998 If continuation sheet Page 15 of 15