Health inspection·July 13, 2023

F 0554 medications. Level of Harm - Minimal harm or potential for actual harm Further record review showed Resident #28 did not have a care plan for self-administering medications and was never assessed for self-administering medications. The Minimum Data Set (MDS), dated [DATE], showed Resident #28 had a Brief Interview for Mental Status (BIMS) score of 09 that showed cognitive function of mildly impaired. A Physicians Evaluations of Resident's Capacity To Make form, dated 06/12/23, showed Resident #28 was Incapacitated to make health care decisions. Residents Affected - Few A review of the facility's policy titled, Resident Self-Administration of Medication, dated 06/01/23, showed, A resident may only self-administer medications after the facility's interdisciplinary team had determined which medication may be self-administered safely. Each resident is evaluated to self-administer medications during the routine assessment by the facility's interdisciplinary team. The care plan must reflect resident self-administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105998 If continuation sheet Page 2 of 32 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 07/13/2023 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 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and resident record review, the facility failed to ensure reasonable accommodations were made for one resident (#74) related to not providing an appropriate length mattress to ensure the resident's feet did not touch the footboard of six residents sampled. Residents Affected - Few Findings included: During an observation and interview conducted on 7/10/23 at 9:55 a.m. Resident #74 said his feet frequently touch the footboard. Resident #74 stated staff need to reposition me although even with the knees raised, I slide right back down. I am 6'7; they don't have a bed for my height. When I requested a longer mattress, I was given this bed and was told this is the longest they have, it will have to do. On 7/10/23 at 12:20 p.m. Resident #74 was observed in his bed sitting up and eating his lunch. His feet were touching the footboard and his heels were not supported by the mattress as there was a gap of approximately 7 ½ inches. (Photographic Evidence Obtained) During an interview with Resident #74 on 7/10/23 at 12:25 p.m., the resident verbalized he has gotten used to his feet pressing on the footboard and he gets tired of having to bother the staff to move him up constantly. I am not able to move myself up in the bed. Resident #74 stated he has told several staff members, nurses, maintenance staff and CNAs (certified nursing assistants). They all continue to say there is nothing more that can be done. During an interview on 7/11/23 at 9:54 a.m., Staff K, Certified Nursing Assistant (CNA) stated Resident #74 does have to be moved up in the bed frequently, so his feet do not rest on the footboard. Staff K, CNA confirmed there was a gap, and his feet were not supported by the mattress even after they pull him up in the bed. During an interview on 7/12/23 at 12:06 p.m., Staff M, CNA stated she had noticed the gap in the length of Resident #74's bed. She continued to state, she found a cushion intended to prevent such a gap. Resident #74 told me the cushion won't fit, it just falls on the floor. Of course I tried to place the cushion between the mattress and the footboard, he was right the cushion just fell to the floor. During an interview and observation on 7/12/23 at 12:18 p.m., Staff P, Licensed Practical Nurse (LPN), validated Resident #74's feet were on the foot board of the bed and heels were not supported by the mattress. Staff P, LPN stated she would speak with Director of Nursing (DON) about different options for the situation, as this is not optimal. During an interview and observation on 7/12/23 at 12:20 p.m. the DON validated Resident #74's feet were hitting the foot board and a gap between the mattress and footboard existed. The DON stated she would have to get with maintenance and the Administrator regarding what could be done. Review of the admission Record for Resident #74 revealed he was admitted to the facility on [DATE] and his diagnoses included metabolic encephalopathy, chronic pulmonary edema, chronic obstructive pulmonary disease (COPD), obesity, weakness generalized, chronic respiratory failure with hypoxia, abnormalities of gait and mobility, lack of coordination, chronic diastolic (congestive) heart failure (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105998 If continuation sheet Page 3 of 32 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 07/13/2023 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 0558 (CHF), functional quadriplegia, and other idiopathic peripheral autonomic neuropathy. Level of Harm - Minimal harm or potential for actual harm A review of the admission Minimum Data Set (MDS) assessment, dated 6/19/23, revealed in Section C Cognitive Patterns a score of 13/15 on the Brief Interview for Mental Status (BIMS) assessment, indicating the resident was cognitively intact. Section G Functional Status indicated Resident #74 needed extensive assist of two person for bed mobility. Residents Affected - Few A review of Resident #74's care plan, initiated on 6/14/23, revealed a Focus area of: Activities of Daily Living (ADL) Care Plan Resident #74 has self-care performance deficit related to his COPD, Brain Damage, CHF and mobility. Interventions added to this care plan on 6/29/23 were: Bed Mobility: The resident is totally dependent times two staff for repositioning and turning in bed. Review of the facility's policy for Accommodation of Needs, dated 10/2022, showed: Policy: The facility will treat each resident with respect and dignity and will evaluate and make reasonable accommodations for the individual needs and preferences of a resident, except when the health and safety of the individual or other residents would be endangered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105998 If continuation sheet Page 4 of 32 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 07/13/2023 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to provide an environment that was clean, sanitary, and well-maintained related to lack of housekeeping three halls (100, 400 and 600) of six halls affecting 12 resident rooms (604, 609, 101, 103, 102, 104, 400, 404, 406, 408, 411, 412 ), two storage areas (600-hall oxygen room, clean utility room) and broken handrails located in the hallway across from the therapy room and the dining room, and failed to ensure the ceiling was free and a black like substance and in good repair in one of one kitchen. Findings included: 1. An observation on 7/10/23 at 9:53 a.m. of the 600-hall oxygen room revealed under an empty oxygen rack dirt and mulch-looking material and behind the door was piles of dead ants intermixed with dust. On 7/10/23 at 10:01 a.m., an observation was conducted in the bathroom for Resident room [ROOM NUMBER]. The observation revealed a black biofilm along the floor and in the corner of the shower, the light above the shower was not working, and the room was very warm as the exhaust fan was not working. On 7/10/23 at 10:12 a.m., an observation was made of the bedside refrigerator in Resident room [ROOM NUMBER], inside the refrigerator was three dead bugs on the bottom and one on a door shelf. The bathroom of the room was very warm and the exhaust fan was not working. On 7/10/23 at 11:24 a.m., on a metal shelf inside the clean utility room was a pump with residual of enteral nutrition dried to it, Staff H, Licensed Practical Nurse (LPN), confirmed the findings. On 7/10/23 at 2:00 p.m., the vanity inside Resident room [ROOM NUMBER]'s bathroom was missing a drawer front and with deteriorated manufactured wood. (Photographic Evidence Obtained) On 7/10/23 at 2:13 p.m. the inside of a refrigerator in Resident room [ROOM NUMBER] was observed the plastic interior of the refrigerator was chipped and not intact. (Photographic Evidence Obtained) On 7/10/23 at 2:22 p.m. an observation was conducted of Resident room [ROOM NUMBER]'s toilet. The toilet bowl had an overall brown residual around the sides. (Photographic Evidence Obtained) On 7/11/23 at 10:34 a.m. an observation was made of the bathroom of Resident room [ROOM NUMBER]. The toilet pedestal was unclean, a plunger labeled sink only was sitting beside the toilet on a brown paper towel, and a water basin was under the toilet's water valve with dried water stains. On 7/11/23 at 5:57 p.m. an observation was conducted of a broken handrail attached to the wall across from the therapy room, above the handrail was unpatched drywall that had been painted the same color as the wall. (Photographic Evidence Obtained) On 7/10/23 at 10:29 a.m., Staff R, Laundry Aide stated they only clean refrigerators in resident rooms if the resident requests, not supposed to go in their refrigerators. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105998 If continuation sheet Page 5 of 32 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 07/13/2023 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 7/12/23 at 11:25 a.m. the Maintenance Director observed the 600-hall oxygen room and reported not knowing who was supposed to be cleaning the room and the material under the oxygen rack was mulch. On 7/13/23 at 12:39 p.m., the Housekeeping Manager stated housekeeping staff were responsible for cleaning resident rooms, common areas, dining room, clean and soiled utility rooms, oxygen room, and all offices. The Housekeeping Manager reported the facility was fully staffed with 10 housekeeping staff. The Housekeeping Manager stated housekeeping staff were supposed to clean refrigerators inside resident rooms, the cobwebs at the end of the 600-hall were supposed to be cleaned daily, dead ants were to be cleaned off surfaces, the bugs inside Resident room [ROOM NUMBER]'s refrigerator should have been cleaned along with the toilet bases. The Housekeeping Manager confirmed the black biofilm on the shower chair in Resident room [ROOM NUMBER]. On 7/13/23 at 12:59 p.m., a tour of the facility was completed with the Regional Maintenance Director (RMD). The RMD confirmed the broken handrail next to the dining room. The RMD acknowledged the exhaust fan in the bathroom of Resident room [ROOM NUMBER] and confirmed the exhaust fan was not working and the room was very muggy. The RMD stated the HVAC (Heating, Ventilation, and Air Conditioning) company will need to come back to the facility. The RMD stated the facility did have a [electronic maintenance system] but did not know if staff had access to it and there was also maintenance books at each unit. A review of the policy titled, Resident Refrigerators, implemented 5/2022 and revised 2/2023, revealed: This facility does not provide a refrigerator in a resident's room. However, it the policy of this facility to ensure safe and sanitary use of any resident-owned refrigerators. The policy explanation and guidelines showed the dormitory-sized refrigerator are allowed in a resident's room under the following conditions, which included: the refrigerator is inspected by maintenance personnel and deemed safe prior to use and upon routine inspections, and identified that nursing/housekeeping staff shall clean the refrigerator and discard any foods that are out of compliance. The policy showed the Accommodations shall be made for the resident to be present for temperature checks, observing food for sanitary storage, and cleaning of the refrigerator, if so desired by the resident. The policy titled, Routine Cleaning and Disinfection, implemented 5/2022 and revised 2/2023, revealed the policy of the facility was to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to be extent possible. The guideline indicated that Routine cleaning and disinfection of frequently touched or visibly soiled surfaces will be performed in common areas, resident rooms, and at the time of discharge. The routine cleaning will focus on visibly soiled surfaces and high touch areas not limited to toilet handles, bed rails, tray tables, call buttons, TV remote, telephones, toilet seats, and monitor control panels, touch screens and cables, sinks and faucets, and door knobs and levers. The policy titled, Preventative Maintenance Program, implemented 5/2022 and revised 2/2023, revealed, A Preventative Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. 2. A tour of the facility kitchen was conducted on 7/10/2023 at 9:41 a.m. During this tour, the ceiling was observed to have cracks/holes in the plaster and a black substance surrounding the condensation vents as well as spotted in areas on the ceiling. (Photographic Evidence Obtained) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105998 If continuation sheet Page 6 of 32 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 07/13/2023 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some These findings were confirmed and discussed during an interview with the facility's Maintenance Director on 7/10/2023 at 9:46 a.m. During this interview the Maintenance Director stated, Yes, we got a lot of rain last night and it appears that we got a leak in the roof. I got a call out for someone to come and take a look at the roof. Once we get that taken care of , I will fix the drywall. 3. An observation was made on 7/10/23 at 10:00 a.m. in the bathroom of Resident room [ROOM NUMBER]. The bathroom toilet had a brown stain in the toilet bowl. The screws for the bowl base were rusted and dusty. An observation was made on 7/10/23 at 10:04 a.m. in the bathroom of Resident room [ROOM NUMBER]. The bathroom toilet had a buildup of dirt and dust in the corner of the wall next to the toilet. On the floor behind the toilet was significant dirt buildup, a dried piece of toilet tissue and dead bugs. The screws for the bowl base were rusted and dusty. An observation was made on 7/10/23 at 10:10 a.m. in the bathroom of Resident room [ROOM NUMBER]. The bathroom door frame had a hole at the bottom of the frame near the floor inside the bathroom where it was rusted out. The rust pieces were on the floor. (Photographic Evidence Obtained) An observation was made on 7/10/23 at 10:20 a.m. in the bathroom of Resident room [ROOM NUMBER]. The floor had dirt build up near the edges of the floor and wall. Bathroom walls near the toilet had a light black substance splattered on the wall. The foot tips of the shower bench had a black shiny bio growth on them. The grout of the shower floor, near where it meets the bathroom floor had black bio growth in the tile grout line. In the room closet a buildup of dirt and dust was in the corners. The base of the wall in the room closest to the floor had a black substance going up the wall. (Photographic Evidence Obtained) An observation was made on 7/10/23 at 10:25 a.m. in the bathroom of Resident room [ROOM NUMBER]. The wall next to the sink had an unpainted area, leaving the drywall exposed. The bathroom toilet had dirt and dust built up around the toilet. (Photographic Evidence Obtained) An observation was made on 7/10/23 at 10:30 a.m., in Resident room [ROOM NUMBER] and the bathroom. The floor had dirt build up near the edges of the floor in the bathroom. The foot tips of the shower bench had a black shiny bio growth on them. The corner of the shower nearest the sink had holes and tile missing. (Photographic Evidence Obtained) On 7/12/23 at 9:45 a.m. an interview was conducted with Staff N, Housekeeping Aide. Staff N stated she cleans the residents' rooms and bathrooms. Staff N stated she must have missed the dust and the equipment is not for housekeeping to clean. If I see soiled equipment, I do try to clean it. If a repair is needed of something, an entry is placed in the maintenance logbook for follow up. On 7/13/23 at 3:00 p.m. an interview was conducted with the Nursing Home Administrator (NHA), regarding the environmental concerns, the photographic evidence was reviewed. The pictures of the rusted out bathroom doorframes were reviewed and the NHA stated that just requires some paint. The NHA continued to state, there is a lot of maintenance that is needed here, we have a lot to do. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105998 If continuation sheet Page 7 of 32 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 07/13/2023 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 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to transmit two comprehensive assessments for one resident (#96) out of two residents sampled for the task of Resident Assessments. Residents Affected - Few Findings included: A review of Resident #96's Minimum Data Set (MDS) information identified a Modification of Entry assessment, dated 2/10/23, was Export Ready, the status of the original Entry assessment was modified and the Modification of admission assessment, dated 2/16/23, was Export Ready. The original admission assessment status was modified. The Discharge Return Not Anticipated assessment, dated 2/28/23 was accepted. On 7/13/23 at 11:26 a.m., during an interview Staff C, MDS Licensed Practical Nurse (LPN) stated they had some issues and couldn't transmit (at that time). The staff member stated both modifications should have been sent and Resident #96's assessments were missed. The policy titled, MDS 3.0 Completion and Transmission, dated 4/5/23, showed Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. The policy guidelines showed an entry assessment was to be completed and submitted with every entry into the facility no later than the entry date + 7 calendar days. The admission assessment must be completed within 14 days of admission, with the day of admission as day 1. The modification information must be corrected with 14 days after identifying the errors. According to the Transmission Requirements: All assessments shall be transmitted to the designated CMS system (QIES ASAP) with 14 days of completion. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105998 If continuation sheet Page 8 of 32 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 07/13/2023 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. An observation on 07/10/23 at 10:32 a.m. showed Resident #77 was being administered oxygen via a nasal cannula at 2 liters per minute (lpm). Residents Affected - Few During an interview on 07/10/23 at 10:32 a.m., Resident #77 stated she was to be administered oxygen continuously. A review of Resident #77's admission Record showed a diagnosis of sleep apnea, unspecified. A review of the July 2023 Medication Administration Record showed two physician orders for oxygen. The first physician order, dated 05/26/23, documented, O2 [oxygen] at 2 lpm via nasal cannula continuous for sleep apnea. The second physician order, dated 06/13/23, documented, O2 [oxygen] at 3 lpm via nasal cannula every shift. The care plan, initiated on 4/10/23, showed Resident #77 was At risk for impaired respiratory status and showed interventions to include, Administer oxygen per order. A review of the Quarterly Minimum Data Set (MDS) Assessment, dated 06/07/23, showed Resident #77 did not use oxygen. During an interview on 07/13/23 at 11:05 a.m., Staff C, LPN MDS stated Resident #77's Quarterly MDS, dated [DATE], the oxygen use was marked No, which was wrong. Staff D, Registered Nurse (RN) MDS also stated, at this time, that oxygen use on Resident #77's Quarterly MDS was marked in error and should have been marked yes. Based on record review, observations, and interviews, the facility failed to ensure the comprehensive Minimum Data Set (MDS) assessment was accurately coded for two residents (Resident #74 and #77) of fourteen sampled residents. Findings included: 1. Review of the admission Record showed Resident #74 was admitted on [DATE] with diagnoses of metabolic encephalopathy, obstructive sleep apnea, chronic pulmonary edema, chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, chronic diastolic (congestive) heart failure and history of COVID-19 (coronavirus disease of 2019). An observation on 7/10/23 at 10:00 a.m. revealed Resident #74 with a non-invasive mechanical ventilator (BiPAP [bilevel positive airway pressure]/CPAP[continuous positive airway pressure]) at his bedside. During an interview on 7/11/22 at 3:00 p.m., Resident #74 stated he has had the BiPAP since his hospital stay. Resident #74 stated he had significant breathing problems that included having a tracheostomy (surgical opening created in the neck into the trachea [windpipe] to allow air to fill the lungs. After creating the opening a tube is placed in the hole which creates the airway and being on a continuous ventilator). He stated he has improved and was able to have the tracheotomy removed before discharging from the hospital, now he only must wear the BiPAP at night. Review of Resident #74's physician orders, dated 6/14/23, revealed an order for BiPAP to be applied every evening. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105998 If continuation sheet Page 9 of 32 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 07/13/2023 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #74's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/19/23 revealed in Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which revealed the resident was cognitively intact. Further review of the MDS revealed no documentation that Resident #74 had a BiPAP, during admission, or prior to admission. During an interview on 7/13/23 at 11:10 a.m., with Staff C, Licensed Practical Nurse (LPN). Staff C, LPN stated she was responsible for completing the section of the MDS that would indicate a Non-Invasive Mechanical Ventilator (BiPAP/CPAP). Staff C, LPN verified the resident had an order for a BiPAP here and had one prior to admission and verified the assessments for non-invasive mechanical ventilator (BiPAP/CPAP) were inaccurately coded. During an interview on 7/13/23 at 9:30 a.m. the Director of Nursing (DON) stated the accuracy of the MDS was important. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105998 If continuation sheet Page 10 of 32 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 07/13/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to confirm the accuracy of a Pre-admission Screening and Resident Review and failed to correct the document for three residents (#10, #105, and #36) out of forty-seven residents sampled when mental illness or suspected mental illness diagnoses were identified and added to the resident's medical diagnoses . Findings included: 1. A review of Resident #10's admission Record indicated an original admission date of 4/2/18 and a recent re-admission date of 3/23/23. The census list for the resident identified additional admission dates of 9/28/18 and 12/14/19. A Preadmission Screening and Resident Review, Level I Screen for Resident #10, dated 4/2/18, indicated N/A in sections A. Mental Illness (MI) or suspected MI and B. Intellectual Disability (ID) or suspected ID. Section II: Other indications for PASRR (PASARR) Screen Decision-Making identified the resident had no indications. Section IV indicated the resident may be admitted to a Nursing Facility (NF) as no diagnosis or suspicion of serious MI (SMI) or ID was identified and a Level II evaluation was not required. The Diagnosis Report for Resident #10 identified the following diagnoses: - unspecified major depressive disorder, single episode - present on admission, onset date 4/2/18 and resolved on 10/1/19. - unspecified mood (affective) disorder - present on admission, onset date 11/20/18. - unspecified anxiety disorder - present on admission, onset date 11/20/18. - schizoaffective disorder bipolar type - present on admission, onset date 9/15/19. - adjustment disorder with anxiety - during stay, onset date 10/1/19. - unspecified recurrent major depressive disorder - during stay, onset date 10/1/19. - other bipolar disorder - during stay, onset date 10/1/19. The comprehensive assessment for Resident #10, dated 6/26/23, identified the resident had active psychiatric/mood disorders of anxiety disorder, depression (other than bipolar), bipolar disorder, schizophrenia, and unspecified mood (affective) disorder. A psychiatry note, dated 6/14/23, included the chief complaints as depression, anxiety, and insomnia. The reason for the encounter was reported to me that patient is unstable requiring psychiatric assessment. The assessment and plan read patient (pt) is unstable but requires no med (medication) changes and the provider felt symptoms were occurring due to exacerbation of underlying depressed disorder. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105998 If continuation sheet Page 11 of 32 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 07/13/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Resident #105's admission Record identified an admission date of 6/1/23. The admission Record for the resident included the diagnosis of schizophreniform disorder due to history and with an onset date of 6/28/23. The Diagnosis Report identified the resident had a history of schizophreniform disorder with an onset date of 6/28/23. The PASARR, dated 4/21/23, and completed at an acute care facility identified that Resident #105 had a documented history of depressive disorder. A review of Resident #105's comprehensive assessment, dated 6/7/23, did not identify that the resident had any psychiatric/mood disorders. A psychiatry evaluation note, dated 6/7/23, identified Resident #105 had chief complaints of depression and schizophrenia. Per the evaluation, the resident was receiving the antidepressant, Escitalopram daily for depression and the antipsychotic medication, Olanzapine twice daily for psychotic disorder. The assessment and plan indicated a gradual dose reduction was considered but based on history, the patient would be unable to tolerate the reduction and would likely become unstable, therefore the provider felt the resident was on the minimal effective doses of the psychotropic medications. 3. A review of Resident #36's admission Record indicated the resident was admitted on [DATE] and 4/28/23. The admission Record included the following diagnoses: - schizoaffective disorder - bipolar type, was present on admission with an onset date of 10/11/21. - schizoaffective disorder - depressive type, history of with an onset date of 5/31/23. The modified 5-day comprehensive assessment, dated 5/4/23, identified Resident #36 had an active diagnosis of schizophrenia. Resident #36's PASARR which was completed at an acute care facility and dated 10/11/21, did not have a documented history of any mental illness or intellectual disability. The resident's PASARR indicated a Level II PASARR evaluation was not required. The amended Cognitive Assessment note, dated 5/5/23, identified the chief complaint of Resident #36 was depression, anxiety, schizoaffective disorder, and pseudobulbar affect. The note indicated the facility was requiring a detailed cognitive assessment as the resident was exhibiting behaviors related to memory problems. The note included the diagnoses of moderate recurrent major depressive disorder, generalized anxiety disorder, depressive type schizoaffective disorder, and pseudobulbar affect and appeared to have major cognitive disorder of mixed etiology. The psychiatry note, dated 6/14/23, indicated Resident #36's chief complaint was depression, anxiety, schizoaffective disorder, and pseudobulbar affect. The plan of action indicated the provider decided to continue the antipsychotic medications of Aripiprazole (Abilify), Geodon, and Fluphenazine for schizoaffective disorder, the anticonvulsant Depakote for mood disorder, and the antidepressant Venlafaxine. On 7/13/23 at 7:41 a.m., the Social Service Director (SSD) stated that either the SSD and/or Director of Nursing (DON) review the PASARRs. The SSD reported they normally do not do the PASARR due to being a Licensed Practical Nurse and not a licensed Social Worker, so the DON and/or Assistant DON deal with them. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105998 If continuation sheet Page 12 of 32 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 07/13/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The DON stated, on 7/13/23 at 9:54 a.m., there was not a Performance Improvement Plan (PIP) (for PASARRs) and have discussed doing an audit but haven't started. The DON reported when the PASARR waiver ended the facility identified they were old or diagnoses had been added but the facility did not have a process. The DON reviewed the PASARR for Resident #10 and concluded the resident did have psychiatric diagnoses and that N/A was not appropriate. The DON stated Resident #105's PASARR was incorrect, it listed depression but should have listed schizoaffective (disorder), and that Resident #36 did have diagnoses that should have been included on the PASARR. The policy titled, Resident Assessment - Coordination with PASARR Program, dated 9/7/22, revealed, This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with mental disorder intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. The guidelines indicated that all applicants to the facility would be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. A Negative Level I Screen permits admission and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later or a Positive Level I indicates that a Level II evaluation is necessary prior to admission. A PASARR Level II is a comprehensive evaluation by the appropriate state-designated authority (cannot be completed by the facility) that determines whether the individual has MD, ID or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs. The policy identified that any resident who exhibited a newly evident or possible serious mental disorder, intellectual disability, or a related condition would be promptly referred to the state mental health or intellectual disability authority for a level II resident review. The examples given included, a resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a mental disorder (where dementia is not the primary diagnosis), and a resident whose intellectual disability or related condition was not previously identified and evaluated through PASARR. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105998 If continuation sheet Page 13 of 32 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 07/13/2023 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 observations, record reviews, and interviews the facility failed to ensure two residents (#93 and #461) of three residents sampled for skin impairments received wound care in accordance with professional standards related to changing dressings as ordered and documented and failed to assess and document skin conditions. Residents Affected - Few Findings included: 1. An observation was conducted on 7/10/23 at 12:27 p.m. of Resident #93 lying in bed, the resident stated the bed sheets were piled. The observation identified an area of rolled gauze, dated 6/27/23, on the right upper arm and a white bordered dressing, dated 7/1/23, on the left knee. On 7/10/23 at 12:39 p.m., Staff P, Licensed Practical Nurse (LPN) observed Resident #93's dressings. Staff P reported not seeing the right upper arm rolled gauze earlier, another nurse was taking care of wounds, and maybe that nurse had dated (6/27/23) it wrong. Staff P removed the resident's sock from the left heel and stated the dressing was dated 7/1/23. The observation identified the left heel of the resident had eschar attached to the wound bed. Staff P, LPN removed the dressing to Resident #93's left knee and confirmed the white dressing was dated 7/1/23. The dressing was soiled with dried red and tan colored drainage. The admission Record for Resident #93 identified the resident was originally admitted on [DATE]. The admission Record included diagnoses not limited to unspecified chronic obstructive pulmonary disease, adult failure to thrive, unspecified bipolar disorder, and unspecified malignant neoplasm of pancreatic duct. A review of Resident #93's Order Summary Report, dated 7/13/23, included a treatment order, dated 5/28/23, as Cleanse left heel with normal saline (NS), pat dry, apply skin prep (to) peri-wound, apply (Collagenase) ointment to wound bed followed by calcium alginate, and cover with dry dressing every evening shift for wound care. A review of Resident #93's June and July 2023 Treatment Administration Records (TARs) included the following treatment orders and documentation: - Cleanse skin tears to right upper arm, left (outer) knee, and left elbow with NS, pat dry, apply Triple Antibiotic Ointment (TAO), and cover with dry dressing daily till resolved every evening shift for skin tears, dated and discontinued on 6/27/23. The TARs did not indicate this dressing had been applied. - Cleanse skin tears to right upper arm and left elbow with normal saline, pat dry, apply (petrolatum gauze), cover with abdominal (abd) pad, and wrap with (rolled gauze) daily till resolved, every evening shift for skin tear. Dated 6/28 and discontinued 7/5/23. The June 2023 TAR indicated the dressing had been applied on 6/28 and 6/29. The printed TAR did not include documentation from 6/30/23. The July 2023 TAR indicated the dressing had been applied 7/1, 7/2, and 7/4. The order had been discontinued on 7/5/23. - Treatment as indicated - Cleanse left heel with NS, pat dry, apply skin prep (to) periwound, apply (Collagenase) ointment to wound bed (followed) by calcium alginate, and cover with (dry) dressing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105998 If continuation sheet Page 14 of 32 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 07/13/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few every evening shift for wound care. The July 2023 TAR indicated the resident's dressing had been changed on 7/1, 7/2, 7/4, 7/5, 7/8, and 7/9, despite the dressing being dated 7/1/23. The TAR indicated the dressing had been refused to be changed on 7/3, 7/6, and 7/7/23. - Cleanse skin tear area bilateral knees with NS, apply dry dressing daily every day shift for wound care and (monitoring). The July TAR indicated that the dressing had been changed on 7/1 and 7/2/23, despite being dated 7/1/23 and staff had not documented the dressing change had been refused on 7/3, 7/4, or 7/5/23. The active care plan for Resident #93 revealed the resident had altered skin integrity non-pressure location: left heel and sacrum wound with an intervention that included: Treatment per order. The care plan identified the resident had a skin tear to left outer knee and left arm and instructed staff that if skin tear occurs, treat per facility protocol and notify MD (medical doctor), family. On 7/12/23 at 2:22 p.m. the Director of Nursing (DON) reported being unaware of the observation of Resident #93's dressings. The DON reviewed documentation and confirmed it was concerning of a dressing that was nine days old. After reviewing the July 2023 TAR the DON confirmed that staff were documenting wound care was being done. 2. A review of Resident #461's admission Record indicated the resident was admitted on [DATE]. The diagnoses included atherosclerotic heart disease of native coronary artery without angina pectoris, diabetes mellitus due to underlying condition with hyperglycemia, paroxysmal atrial fibrillation, and essential (primary) hypertension. The Wound Care Services note from the transferring acute facility, dated 12/26/22, identified Resident #461's wounds as follows: - right great toe, distal tip with unstable eschar surrounded by red moist tissue. Protocol was initiated: cleanse (with) NS, apply (petrolatum) gauze to wound area and cover with silicone border foam dressing. - right plantar distal 3rd toe, diabetic ulcer superficial 100% red, protocol initiated: cleanse (with) NS, apply (petrolatum) to wound area and covered (with) silicone border foam dressing. The Medical Certification For Medicaid Long-Term Care Services and Patient Transfer Form (AHCA Form 3008), dated 1/2/23, the facility had received from the acute facility identified in Section T Skin Care - Stage Assessment, right big toe wound, left big toe starting to be necrotic. The Admission/readmission Nursing Evaluation, dated 1/2/23, indicated Resident #461 was admitted with discoloration to the right and left toes without any additional skin impairments. The Head to Toe Weekly Skin Check, effective 1/9/23, identified Resident #461 had an existing skin impairment of a skin tear to the right forearm and did not have any resolved skin impairment. The skin check did not identify discoloration to the right and/or left toes. The Advanced Practitioner Registered Nurse (APRN) notes,, dated 1/3, 1/16, and 1/19/23, indicated Resident #461 did not have any rash, lesions, or petechiae (small red or purple spot caused by bleeding into the skin). The assessment identified the resident did have right third and great toe necrosis, with skin care as indicated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105998 If continuation sheet Page 15 of 32 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 07/13/2023 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The Wound Care Specialist noted on 1/4/23, identified right knee and a left hand trauma wounds that were present on admission. The measurement of the right knee was 1.8 x 2.8 x 0.3 centimeters with 100% granulation tissue. The specialist ordered the wound to be cleaned with wound cleanser, petrolatum to be applied and the dressing changed three times a week and the left hand to be cleansed with wound cleanser three times a week. The note indicated the treatment was discussed with the nurse (unidentified) and the plan was for petrolatum gauze. The Wound Care Specialist noted on 1/11/23 that both the Right knee and Left hand was resolved and that skin prep was to be applied daily for one week as resolved wounds do not achieve their original tensile strength (measurement of the wounds load capacity per unit area). It is possible for wounds to recur. A review of Resident #461's care plan included a focus that identified the resident has potential/actual impairment to skin integrity related to (r/t) resolved right knee and left hand, initiated on 1/3/23 and revised on 2/1/23. The nutrition care plan indicated the resident was at risk for altered nutrition status secondary to diagnosis (dx) dementia, diabetes mellitus (DM), heart disease, GERD, wounds, (and) receives therapeutic diet. The review of Resident #461's January Medication and Treatment Administration Records (MAR/TAR) did not include wound care orders for the necrotic toes, the skin tear to the right forearm noted on the 1/9/23 Weekly Skin Check, the right knee, and/or left hand skin tears. A nursing note, dated 1/22/23 at 12:43 p.m., identified Resident #461 was found to have open area to left great toe, wound was cleaned and dressed. A nursing note, dated 1/22/23 at 4:28 p.m. revealed Resident #461's family member checked the resident's skin prior to discharging home and noted sock was dried to right toe. [Staff H, Licensed Practical Nurse (LPN)] was called to look at top of the resident's right great toe, looked like his toe had been bleeding and dried up. The staff member noted that wound cleanser was used to clean it and applied (Collagenase) and wrapped with rolled gauze. On 7/12/23 at 2:07 p.m., the DON stated the expectation would be to monitor the toes and dependent on how they looked and condition; to be doing wound care if necessary and per wound physician orders. The DON stated the expectation would be that someone else observe the wound as a second opinion within 24 hours and the Unit Manager would have been aware of the toes after admission. The DON reported if a resident had a skin condition, staff would let the attending physician know and it would be up to their discretion if the wound care specialist would be consulted. The DON stated at the time of Resident #461's admission the Unit Manager or the DON was getting the Wound Care specialist notes and that orders would be written in the electronic record or the Unit Manager would take a verbal order and put it in the record. The DON reviewed Resident #461's record and confirmed there were no orders for wound care and there was no description of the right knee and/or left hand trauma wounds at the time of admission or elsewhere. The Skin Evaluation policy, implemented 8/22/22, revealed, It is our policy to perform a full body skin evaluation as part of our systematic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body identified pressure injury. The explanation documented the staff should begin head to toe, thoroughly examining the resident's skin for condition, remove any special garments or devices if not contraindicated or ordered to remain in place, remove any dressings and note findings, and note any skin conditions such as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105998 If continuation sheet Page 16 of 32 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 07/13/2023 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 redness, bruising, rashes, blisters, skin tears, open areas, ulcers, and lesions. Level of Harm - Minimal harm or potential for actual harm The Wound Treatment Management policy, implemented 8/25/22, revealed, To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. The guidelines revealed: Residents Affected - Few - Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. - In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse. - Treatments will be documented on the Treatment Administration Record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105998 If continuation sheet Page 17 of 32 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 07/13/2023 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review and interview the facility failed to ensure two oxygen administration orders were clarified for one resident (#77) of two residents reviewed for respiratory care. Residents Affected - Few Findings included: An observation on 07/10/23 at 10:32 a.m., showed Resident #77 was being administered oxygen via a nasal cannula at 2 liters per minute (lpm). During an interview on 07/10/23 at 10:32 a.m., Resident #77 stated she was to be administered three liters of oxygen continuously. A review of Resident #77's admission Record showed a diagnosis of sleep apnea, unspecified. A review of the July 2023 Medication Administration Record showed two physician orders for oxygen. The first physician order, dated 05/26/23, documented, O2 [oxygen] at 2 lpm via nasal cannula continuous for sleep apnea. The second physician order, dated 06/13/23, documented, O2 [oxygen] at 3 lpm via nasal cannula every shift. The care plan, initiated on 4/10/23, showed Resident #77 was At risk for impaired respiratory status and showed interventions to include, Administer oxygen per order. During an interview on 07/12/23 at 2:31 p.m., the Director of Nursing (DON) confirmed there were two separate physician orders for Resident #77. The DON confirmed that both oxygen administration orders had different liters per minute ordered, contradicting each other. The DON stated those two oxygen administration orders will need to be clarified with the doctor to determine which oxygen flow rate was correct. A review of the facility's policy titled, Oxygen Administration, revised date 02/2023, showed, 1. Oxygen is administered under orders of a physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105998 If continuation sheet Page 18 of 32 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 07/13/2023 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 Based on observation, record review and interview the facility failed to ensure continuous communication with the dialysis center for one resident (#31) out of two residents reviewed for dialysis services. Residents Affected - Few Findings included: During an interview on 07/10/23 at 10:09 a.m., Resident #31 stated he received dialysis services three days a week. A review of Resident #31's admission Record showed an admission date of 12/1/22 and diagnoses to include chronic kidney disease without heart failure, with Stage 5 chronic kidney disease, or end stage renal disease. A review of the July 2023 physician orders showed a physician order, dated 12/04/22, showed, Dialysis: May go to Dialysis on: Monday, Wednesday, Friday. A second physician order, dated 12/04/22, showed, Complete Dialysis communication form and send with Resident to dialysis center. A third physician order, dated 12/04/22, showed, Complete post communication dialysis form on return. A review of the care plan showed Resident #31 had a care plan focus, initiated on 12/5/22 and revised on 12/15/22, of Dialysis Care Plan: Renal failure with dialysis and interventions included: Review Dialysis communication forms. There was one Dialysis Communication Form found scanned in Resident #31's electronic medical record and dated 06/26/23. An observation on 07/11/23 at 5:35 p.m., revealed no dialysis communication book was available for Resident #31. During an interview on 07/11/23 at 5:40 p.m., Staff B, Licensed Practical Nurse (LPN) stated Resident #31 had a dialysis communication book but could not find it. Staff B, LPN found Resident #31's dialysis communication book and stated, Resident #31 had it in his room. Staff B, LPN stated, To be honest the dialysis communication book is rarely used. Staff B, LPN stated she usually just obtains Resident #31's vital and status information on post dialysis from the transportation people. Staff B, LPN stated, the last Assistant Director of Nursing (ADON) trained me and said nurses didn't have to use the dialysis communication book any longer, as nurses just needed to document everything in the computer. A review of Resident #31's dialysis communication book, on 07/11/23 at 5:45 p.m., showed three pre-communication forms for the dates of 07/05/23, 07/07/23 and 07/10/23. There were no dialysis communication forms present in Resident #31's dialysis communication book. (Photographic Evidence Obtained) Review of Post Dialysis communication forms showed no communication between the dialysis center and the facility. The Post Dialysis Communication forms are assessments completed by the nurse at the facility of Resident #31's status upon return to the facility after dialysis services. The following Post Dialysis Communication forms were as followed: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105998 If continuation sheet Page 19 of 32 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 07/13/2023 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 07/10/23- No received information regarding treatment from dialysis Level of Harm - Minimal harm or potential for actual harm 07/05/23- No received information regarding treatment from dialysis 06/28/23- No received information regarding treatment from dialysis Residents Affected - Few 06/19/23- No received information regarding treatment from dialysis 06/14/23- No received information regarding treatment from dialysis 06/13/23- No received information regarding treatment from dialysis 06/07/23- No received information regarding treatment from dialysis During an interview on 07/12/23 at 2:27 p.m., the Director of Nursing (DON) stated if the nurse did not receive communication from the dialysis center, I would expect the nurse to call to get a report on the resident, if no written communication was returned with the resident. The DON stated it was expected to be a two way communication between facility and dialysis center. A review of the facility's policy titled, Coordination of Hemodialysis Service, revised date 07/02/23, showed, The Dialysis Communication form will be initiated by the facility for any resident going to ESRD [End Stage Renal Disease] center for Hemodialysis. Nursing will collect and complete the information regarding the resident to send to the ESRD Center. The ESRD facility is to review the Dialysis Communication form and either Complete the communication from and return with the resident or provide treatment information to the facility. 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 or other ancillary departments as needed, implement interventions as appropriate. Nursing will complete the post dialysis information on the Dialysis Communication form and file the completed form in the Resident's Clinical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105998 If continuation sheet Page 20 of 32 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 07/13/2023 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm 2. On 7/11/23 at 8:24 a.m., an observation was conducted with Staff H, LPN of Resident #45's medication administration. Staff H placed a blood pressure cuff on the resident's upper right arm, took it off placed it on the right forearm, and obtained a blood pressure of 118/75. Staff H dispensed a tablet of 25 milligram (mg) Atenolol, 10 mg tablet of Baclofen, and a 100 mg gel cap of Docusate sodium. Staff H placed the medication cup into the top drawer, re-entered the room and obtained a pain level of 9 out of 10 in the back and legs of the resident. Staff H dispensed one tablet of Oxycodone/Acetaminophen 5-325 mg and returned to the room to administer the four tablets. Residents Affected - Few The Order Summary Report included the physician order: Atenolol 25 mg tablet - Give one tablet by mouth one time a day for hypertension, hold if systolic blood pressure less than 140 and diastolic blood pressure less than 90. A review of Resident #45's July Medication Administration Record (MAR) indicated that the resident had been administered Atenolol when staff documented blood pressures outside parameters to hold as follows: 7/1- 133/78, 7/2- 128/73, 7/3- 136/74, 7/5- 129/78, 7/6- 137/77, 7/7-130/75, 7/8- 127/69, 7/9- 123/74, 7/10129/70, 7/11- 118/75, 7/12- 134/81, and 7/13/23- 129/78, a total of twelve times out of 13 administrations. An interview on 7/13/23 at 1:51 p.m. was conducted with the DON. The DON reviewed Resident #45's Atenolol administration record, and stated, I see what you mean. (regarding parameters). The policy - Medication Administration, implemented on 3/24/23, identified that Medications are administered by licensed nurses, or to her staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. The explanation and guidelines instructed staff to Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. Based on record review and interviews the facility failed to ensure staff administered medication with adequate indication for use and monitored the administration and effectiveness of this medication for one resident (#21) out of 28 sampled residents; and administered antihypertensive medication outside physician ordered parameters twelve out of thirteen administrations reviewed for one (#45) out of five residents observed during the task of medication administration. Findings included: 1. A review of Resident #21's admission Record showed diagnoses of insomnia unspecified, anxiety disorder, unspecified dementia with behavioral disturbance and disorganized schizophrenia. A review of medical record revealed a nursing progress note, dated 06/05/23, and showed, resident was very upset all evening, claiming devil was in my belly resident wouldn't take melatonin for sleep, (gave her pudding with melatonin in it to calm her). A review of Resident #21's June 2023 Medication Administration Record (MAR) showed no physician order for Melatonin. The June 2023 MAR showed no Melatonin was provided to Resident #21 during the month of June 2023. The active care plan was reviewed and was silent of a focus for insomnia. During an interview on 07/12/23 at 10:40 a.m., the Nursing Home Administrator (NHA), Regional Clinical Nurse Consultant (RCNC) and the Director of Nursing (DON) reviewed the 06/05/23 progress note. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105998 If continuation sheet Page 21 of 32 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 07/13/2023 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 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The NHA, RCNC and DON were not aware of the progress note and stated they would be looking into this information more. During an interview on 07/12/23 at 11:23 a.m., Resident #21's Psychiatric Nurse Practitioner (PNP) stated she was not aware of Resident #21 having any insomnia issues lately. The PNP stated Resident #21 does have intermittent hallucinations. The PNP stated she assessed Resident #21 once a month and as needed. The PNP stated she expected facility staff to notify the PNP when Resident #21 had hallucinations. The PNP stated that Melatonin should only be given when prescribed by a physician and it was not in the normal scope of practice to administer Melatonin to calm a resident down. During an interview on 07/12/23 at 11:45 a.m., Staff B, Licensed Practical Nurse (LPN) stated Resident #21 was on her regular caseload. Staff B, LPN stated lately Resident #21 had been very irate and thrashing her legs around. Staff B, LPN stated Resident #21 was going downhill because Resident #21 used to be very easy to get along with, however, lately Resident #21 had been talking a lot to herself and agitated. Staff B, LPN stated she had been administering Melatonin to Resident #21 intermittently for a couple months and stated yes, she texted the doctor, to ask if she could administer Melatonin to Resident #21. Staff B, LPN stated the doctor texted back on 04/25/23 that Staff B, LPN could administer Resident #21 Melatonin 5 mg (milligrams) once a day at bedtime (qhs). Staff B, LPN shared the text message on her personal cell phone with the survey team where it was confirmed Resident #21's doctor (phone number verified) texted an order showing, Yes, give Melatonin 5 mg qhs. Staff B, LPN stated the next step would have been to administer Resident #21 the Melatonin. Staff B, LPN was asked if she transcribed the physician order into Resident #21's medical record and she responded, If it's not there, I didn't do it. Staff B, LPN was unable to describe the process of entering a physician order into a medical record when asked. Staff B, LPN stated when she provided any resident with medication she always signed them off the Medication Administration Record (MAR). Staff B, LPN reviewed the June 2023 MAR and could not find Melatonin on Resident #21's MAR. Staff B, LPN stated, I only give it to her when I think she needs it. I don't wake her up to give her Melatonin. Staff B, LPN stated she had administered Resident #21 Melatonin intermittently since getting permission from the physician to do so on 04/25/23. During an interview on 07/12/23 at 12:10 p.m., Resident #21's Primary Care Physician (PCP) stated Resident #21 had a few restless nights and remembered sending a text to Staff B, LPN on 04/25/23 instructing Staff B, LPN to give Resident #21 Melatonin 5 MG by mouth qhs. Resident 21's PCP stated that it was his expectation the nurse would have transmitted the order to Resident #21's medical record and on the Medical Administration Record (MAR). Resident #21's PCP stated the appropriate use for Melatonin was not for calming down a resident with psychological or anxiety symptoms but to aide in sleeping when a resident had insomnia. During an interview on 07/12/23 at 12:55 p.m., the RCNC and the DON stated nurses could receive physician orders by phone calls to the doctor's cell phone or on-call service. The RCNC stated some doctors do prefer texting but the facility had no agency phones so staff would have to use personal phones to text with a doctor. The RCNC stated staff, when texting a doctor, should transcribe the physician order into the medical record immediately. The DON stated Staff B, LPN did not transcribe the physician order to Resident #21's medical record per facility policy so therefore the medication did not go onto the MAR to administer. The RCNC stated all nurses are trained to not administer medications unless the medication was signed off on the MAR, however Staff B, LPN did not follow the facility policy in this situation. The DON confirmed the appropriate use of Melatonin should not be used to calm a resident down but used to assist with restlessness and insomnia symptoms. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105998 If continuation sheet Page 22 of 32 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 07/13/2023 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 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete A review of the facility's policy titled, Medication Orders, dated 08/25/22, showed, 2. Verbal orders should be received by a licensed nurse, or pharmacist, and confirmed in writing by the physician, on the next visit to the facility. 4. Documentation of Medication Orders: a. Each medication order should be documented with the date, time, and signature of the person receiving the order. The order should be recorded on the physician order sheet, and the Medication Administration Record (MAR). b. Clarify the order. c. Enter the order on the medication order and receipt record. d. If using electronic medication records, input the medication order according to the electronic health record instructions and facility policy. e. Call or fax the medication order to the provider pharmacy. f. Transcribe newly prescribed medications on the MAR or treatment record to ensure the order is in the electronic MAR. g. When a new order changes the dosage of a previously prescribed medication discontinued software instructions and retype the new order. h. Enter the new order on the MAR or ensure the new order is in the electronic MAR. i. Notify the resident's sponsor/family of new medication order. Event ID: Facility ID: 105998 If continuation sheet Page 23 of 32 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 07/13/2023 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, record reviews, and interviews the facility failed to ensure that the medication error rate was less than 5.00%. Thirty medication administration opportunities were observed and three errors were identified for two residents (#45 and #70) of five residents observed. These errors constituted a 10% medication error rate. Residents Affected - Few Findings included: 1. On 7/11/23 at 8:24 a.m., an observation of medication administration with Staff H, Licensed Practical Nurse (LPN), was conducted with Resident #45. Staff H placed an electronic blood pressure cuff on the upper portion of the resident's right arm, then removed it, placing it on the lower right forearm and obtained a blood pressure of 118/75 and a pulse of 80. Staff H returned to the medication cart and dispensed the following medications: - Atenolol 25 milligram (mg) tablet - Baclofen 10 mg tablet - Docusate Sodium 100 mg gelcap - Oxycodone/Acetaminophen 5-325 mg tablet Staff H confirmed a total of 4 tablets were dispensed, re-entered the resident's room and administered the medications. The Order Summary Report, dated 7/13/23, included the following physician order: - Atenolol 25 mg tablet - Give 1 tablet by mouth one time a day for hypertension (HTN). Hold if systolic blood pressure (SBP) less than 140 and diastolic blood pressure (DBP) less than 90. This order was started on 11/9/22. The July 2023 Medication Administration Record (MAR) identified Staff H had administered the antihypertensive medication to the resident despite the ordered parameters. 2. On 7/11/23 at 9:31 a.m., an observation of medication administration with Staff A, LPN was conducted with Resident #70. Staff A dispensed the following medications: - Metformin 500 mg tablet - Carvedilol 3.125 mg tablet - Glimepiride 2 mg tablet - Jardiance 10 mg tablet - Potassium Chloride 10 milliequivalent (meq) Extended Release capsule - Entresto 24-26 mg tablet (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105998 If continuation sheet Page 24 of 32 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 07/13/2023 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 0759 - Isosorbide Mononitrate Extended Release 30 mg tablet Level of Harm - Minimal harm or potential for actual harm - Metoprolol Tartrate 25 mg tablet Residents Affected - Few Staff A, LPN confirmed the dispensing of 8 tablets and stated the pharmacy would have to be called for the resident's Bumex. The resident removed the Potassium capsule which Staff A stated that sometimes will take it and offered to call the physician to get a liquid order for it. Staff A left the room and obtained 2 - 0.5 mg tablets of Bumetanide (Bumex) from the facility's electronic medication dispensary. The resident was administered the 2 tablets. A review of the Resident #70's July 2023 MAR identified that the resident's Isosorbide and Jardiance was scheduled for 8:00 a.m. The progress notes, dated 7/11/23, did not indicate the physician was notified of the late medications. On 7/13/23 at 1:51 p.m., an interview was conducted with the Director of Nursing (DON). The DON reviewed Resident #45's MAR and confirmed that staff were administering Atenolol despite the parameters. The DON stated the expectation for late meds was for the doctor and family to be notified and (receive) instructions on how to proceed. If okay to give (medication) and if it was a medication ordered for twice a day the second dose should be adjusted. The policy titled, Medication Administration, implemented on 3/24/23, revealed: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. The compliance guidelines instructed staff to Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medications for those vital signs outside the physician's prescribed parameters. The guidelines continued to indicate that staff were to Review MAR to identify medication to be administered and If any medication is not available, or the possibility of late administration, the nurse will contact the Attending Physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105998 If continuation sheet Page 25 of 32 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 07/13/2023 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) On 7/12/23 at 2:36 p.m., an observation was conducted with Staff H, Licensed Practical Nurse (LPN) of wound care for Resident #105. The staff member was assisted by Staff G, Certified Nursing Assistant (CNA) and Staff Q, LPN. Residents Affected - Some The resident's room was posted for staff to observe Enhanced Barrier Precautions (EBP) which instructed providers and staff to wear gloves and a gown for the following High-Contact Resident Care Activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs, or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy, and wound care: any skin opening requiring a dressing. Staff G, CNA was observed standing on the far side of Resident #105's bed wearing gloves and no gown, the residents' linens were touching the clothing of the staff member. Staff H, LPN entered the room, without donning a gown, and cleaned the over-bed table. Staff Q, LPN who was not wearing Personal Protective Equipment (PPE) stood next to the resident bed and handed Staff G the urinary drainage bag who placed it on the side of the bed next to the wall. Staff H placed barrier on over-bed table, went into the hallway where the treatment cart was parked next to the PPE storage chest. The staff member removed wound care supplies and re-entered the room. Staff G and Staff Q were standing on the same side of the bed. Staff Q moved to the interior side of bed and assisted with removal of the resident's incontinency brief and provided hygiene care. Staff H was observed cutting the alginate pad with scissors that had not been observed to be cleaned prior. The staff member performed wound care without donning a gown, Staff G and Q assisted with positioning the resident without wearing PPE gowns. Immediately following the observation of the wound care for Resident #105, while standing at the treatment cart in the hallway outside of the residents' room, Staff H reported not noticing the EBP sign or the PPE caddy and stated she should have been dressed (in PPE) but would have to check it. On 7/12/23 at 3:24 p.m., the Director of Nursing (DON) and Regional Director of Clinical Services (RDCS) were notified of the observation of wound care for Resident #105. The RDCS stated Enhanced [NAME] to my existence. 4) On 7/13/23 at 6:48 a.m., an observation was conducted on the 100 hallway of the facility. rooms [ROOM NUMBERS] were observed with EBP signage on the doors. No PPE caddies were observed in the hallway available for use by staff or visitors. Staff F, Licensed Practical Nurse (LPN), reported on 7/10/23 at 10:53 a.m., of not knowing why they have EBP posted, There is no COVID. The staff member stated the previous DON had started it and the facility hadn't taken the signs down. Two rooms on the 100-hall were posted with EBP and stated PPE was available in a room and pointed toward the nursing station where staff could get PPE from Central Supply. Staff F stated PPE could be worn in the EBP rooms If you feel safer. On 7/10/23 at 11:53 a.m. the DON stated staff were to use PPE when doing direct care with residents under EBP, which included linen changes. She then stated staff do not need to use PPE in an EBP for linen changes. The EBP signs posted on the units instructed staff and providers to wear gloves and a gown for the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105998 If continuation sheet Page 26 of 32 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 07/13/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some following High-Contact Resident Care Activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs, or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy, and wound care: any skin opening requiring a dressing. 5) On 7/11/23 at 8:41 a.m., an observation was conducted of Staff O, LPN during the task of medication administration. Staff O, LPN fingernails were painted a dark teal color, extended approximately 1 inch past the tip of the finger, and pointed. The staff member responded Don't start with me in regard to the color of the fingernails. The facility Dress Code and Personal Hygiene policy indicated the following: To maximize our residents' well-being, fingernails must be clean and clipped short, and chin-length or longer hair must be secured away from the face in a clean looking fashion, if you provide direct care to residents. The Center of Disease Control and Prevention (CDC), located at https://www.cdc.gov/handhygiene/download/hand_hygiene_core.pdf, indicated that fingernail length can often harbor potential pathogens even with careful handwashing. Natural nail tips should be kept to 1/4 inch in length. and gram-negative pathogens are more likely to be harbored with healthcare workers who wear artificial nails and should not be worn when having direct contact with high-risk patients. 6) During an interview, on 07/10/23 at 12:25 p.m., Staff F, LPN stated the Enhanced Barrier Precaution (EBP) signs are tricky. Staff F, LPN stated the EBP signs were originally placed to let staff know the resident had a catheter, wounds, feeding tube, or on dialysis to give staff an idea there was something about the resident to be careful with. LPN F stated the facility just put Personal Protective Equipment (PPE) outside some doors with EBP signs while other doors with EBP signs still do not have PPE. Staff F, LPN stated, Now what do I do. There is nothing clear about the designated EBP rooms now. There seemed to be no set guidelines, so we don't know, should we don PPE or not? During an interview, on 07/10/23 at 12:30 p.m., Staff A, LPN stated the EBP signs were used to identify a resident with catheters, wounds, a feeding tube or was on dialysis. Staff A, LPN stated, The facility just went around placing PPE bins outside of some of the EBP rooms so right now I am confused. It's just not clear as to what EBP room PPE should be worn. A review of the facility's policy titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to prevent spread of Multidrug Resistant Organisms (MDROs), dated 07/12/22, revealed the following: Enhanced Barrier Precautions- Nursing home residence with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDRO's. The use of gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply. The Enhanced Barrier Precautions high contact resident care activities included: Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens and Changing briefs or assisting with toileting. Based on observations, interviews, and record reviews the facility 1) failed to ensure staff appropriately donned Personal Protective Equipment (PPE) prior to entering isolation rooms for two residents (#74 and #561) out of two residents on Contact Precautions, and 2) failed to ensure staff were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105998 If continuation sheet Page 27 of 32 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 07/13/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm educated on Enhanced Barrier Precautions (EBP) on two hallways (400 and 100) out of six hallways in the facility, 3) failed to implement proper PPE during wound care for one resident (#105) out of one wound care observation, and 4) failed to ensure staff followed proper infection control practices related to nail care during medication administration. Residents Affected - Some Findings included: 1) On 7/12/2023 at 10:30 a.m. an Enhanced Barrier Precautions sign was observed on Resident #74's room door and no PPE caddy available to staff. (Photographic Evidence Obtained) On 07/12/23 at 11:06 a.m. an interview was conducted with Staff H, Licensed Practical Nurse (LPN). Staff H, LPN stated she was informed during her nurse-to-nurse communication from last night an order was received to test Resident #74 for Clostridium Difficile Colitis (C. Diff). Staff H, LPN proceeded to state the nurse from the night shift should have placed Resident #74 on Contact Isolation, when she received the order. Staff H, LPN validated there was no order and no sign on the door for Contact Isolation. On 7/12/23 at 11:15 a.m. Staff N, housekeeping aide (HA) was observed entering Resident #74's room without PPE in place. Staff N, HA proceeded with her normal cleaning duties including dusting, wiping of resident areas, bathroom cleaning and mopping. Staff N, HA exited the room and proceeded to clean the next resident room. An interview was conducted on 7/12/2023 at 11:30 p.m. with Staff P, LPN. She stated Resident #74 should have a Contact Isolation sign on the door. Staff P, LPN retrieved and placed an isolation caddy outside of the door. A review of the Physician orders for Resident #74 revealed an order for Contact Isolation for C. Diff was written at 12:28 p.m. on 7/12/23. An observation of Resident #74's door on 7/12/23 at 12:45 p.m. revealed an EBP sign on the door. Staff M, Certified Nursing Assistant (CNA) was in the resident's room delivering the lunch tray. She was observed without PPE in place. Staff M was observed touching the over bed table with her scrubs while delivering the resident lunch tray. An observation and interview was conducted on 7/12/23 at 1:30 p.m. with Staff P, LPN. She stated a Contact Isolation sign had not been placed on the door for Resident #74 and the EBP sign was still in place. Staff P, LPN proceeded to place the Contact Isolation sign on Resident #74's door according to the physician order. An interview was conducted on 07/12/23 at 11:00 a.m. with the Director of Nursing (DON) and the Infection Preventionist (IP). They stated the process with C. Diff is to place the resident on Contact Isolation as soon as the order is received. The nurse receiving the order would place the signage and PPE on the door to inform staff of the change. A review of the Medical Record revealed Resident #74 was admitted to the facility on [DATE] with diagnoses to include: Metabolic encephalopathy, Obstructive Sleep Apnea, Chronic Pulmonary edema, Chronic Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease, Chronic Diastolic (Congestive) Heart Failure and History of Covid-19. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105998 If continuation sheet Page 28 of 32 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 07/13/2023 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 0880 A review of Resident #74's Physician orders revealed the following orders: Level of Harm - Minimal harm or potential for actual harm 6/14/23 EBP related to wounds. 7/1/23 Droplet precautions for 10 days due to Covid 19 positive. Residents Affected - Some 7/11/23 at 6:46 p.m. C. Diff laboratory for diarrhea. On 7/10/2023 at 10:55 a.m. an observation of Resident #561's room door revealed signage indicating the resident was under Contact Isolation Precautions. A caddy with various PPE items was hanging on the door. Staff I, Occupational Therapist (OT) was observed exiting Resident #561's room with a walker and two small hand weights in her hands. Staff I, OT stated Resident #561 was on Contact Precautions for an infection of a wound and was on intravenous antibiotics. Staff I, OT stated Contact Precautions meant she needed to wear a gown and gloves to enter the resident's room. Staff I, OT stated the equipment was not cleaned prior to exiting the resident room. The equipment would be taken back through the hallways with her ungloved hands to the therapy gym for appropriate cleaning with germicidal wipes. On 7/10/23 at 11:00 a.m. Staff G, CNA was observed entering and exiting Resident 561's room without donning or doffing any PPE. When Staff G, CNA exited the room, she did not utilize any ABHS (alcohol-based hand sanitizer). On 7/10/23 at 12:49 p.m. Staff J, CNA was observed entering Resident #561's room without donning/doffing of PPE. Staff J exited the room and went directly to the next room without utilizing ABHS. A review of the Medical Record revealed Resident #561 was admitted to the facility on [DATE] with a diagnosis of a wound to a lower extremity with Methicillin-Resistant Staphylococcus Aureus (MRSA) with orders for Contact Isolation. 2) A tour was conducted on 7/10/23 at 10:58 a.m. of the 400 unit in the facility. An observation was made of Staff G, Certified Nursing Assistant (CNA) in room [ROOM NUMBER]-A changing bed linen and making the bed. There was a sign on the door to room [ROOM NUMBER] that revealed Enhanced Barrier Precautions (EBP) were in place. The sign indicated use of a gown and gloves were required when providing direct care. Staff G, CNA was observed with no gown or gloves on while changing the linen. An interview was conducted with Staff G, CNA on 7/10/2023 at 10:58 a.m. Staff G stated EBP meant she only had to wear gown and gloves when providing patient care. Staff G, CNA stated she did not think changing dirty linen was direct patient care. An interview was conducted on 7/10/23 at 12:35 p.m. with Staff H, Licensed Practical Nurse (LPN). Staff H, LPN stated EBP meant just normal Universal Precautions of a gown and gloves being worn when caring for residents. She continued to explain Contact Precautions require a gown and gloves whenever entering a room for any reason. An interview was conducted on 7/10/2023 at 12:55 p.m. with Staff K, CNA. Staff K, CNA stated EBP is used for Covid residents and requires use of a gown, mask, eye protection and gloves. Staff K, CNA continued to explain Contact Isolation is for everything else, and she wears a gown and gloves when providing resident care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105998 If continuation sheet Page 29 of 32 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 07/13/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Multiple observations were conducted on 7/10/23 throughout the day on the 400 unit of the facility. room [ROOM NUMBER] was the only room with EBP signage on the door. rooms [ROOM NUMBERS] had signage on the doors indicating Contact Isolation. PPE caddies were observed on all three doors in the hallway. On 7/11/23 at 9:00 a.m. an observation of the 400 unit of the facility was conducted. Multiple rooms including, 411, 409, 407, 406, and 403 were observed with EBP signs on the door. No PPE caddies or carts were next to the EBP rooms. room [ROOM NUMBER] was observed to have a Contact Isolation sign on the door. On 7/11/23 at 9:05 a.m. Staff H, LPN was interviewed. Staff H, LPN stated she was caring for the resident in room [ROOM NUMBER]. Staff H, LPN stated the room was not on any isolation precautions on 7/10/2023, and last night management placed EBP signs on resident's door if they had an increased risk of acquiring a Multiple Drug Resistant Organism (MDRO). Staff H, LPN stated signs for EBP were now on four additional rooms, although the resident's conditions remained the same. Staff H, LPN stated she had not seen any different education or materials related to the changes other than the signs should have been on the rooms all along. A review of the facility policy titled Management of C. Difficile Infection implemented: 5/2022 revealed the following: Policy the facility implements facility-wide strategies for the prevention and spread of Clostridioides Difficile (C. Diff) infections. The policy also revealed under explanations and compliance guidance that nurses may implement preemptive contact precautions when C. difficile infection is suspected, pending results of testing. General principles relating to contact precautions for C. difficile: all staff are to wear gloves and a gown upon entry into the resident's room and while providing care for the resident with C. difficile infection. Hand hygiene shall be performed by handwashing with soap and water in accordance with the facility policy for hand hygiene. Maintain on contact precautions for duration of illness, but no less than 48 hours after diarrhea has resolved. Encourage/assist residents to wash hands frequently. Bathe daily with soap and water. Use disposable equipment whenever possible. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105998 If continuation sheet Page 30 of 32 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 07/13/2023 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and facility policy review, the facility failed to ensure an effective pest control system was in place in four halls (100, 200, 400 and 600) of six halls and one resident (#60) who resided in one of the affected halls. Residents Affected - Some Findings included: A review of a facility policy titled, Pest Control, revised date: 2/2023, revealed: It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. Effective pest control program is defined as measures to eradicate and contain common household pests (e.g., bed bugs, lice, roaches, ants, mosquitos, flies, mice and rats). During multiple facility tours, observations were made of live and dead pests and flying insects in resident rooms and storage areas as follows: 1. On 7/10/23 at 10:04 a.m. in the bathroom of Resident room [ROOM NUMBER] an observation revealed dead and live cockroaches near the toilet and shower drain. On 7/10/23 at 10:10 a.m. in the bathroom of Resident room [ROOM NUMBER] an observation was made of small ants in the resident's bathroom sink, both dead and alive. (Photographic Evidence Obtained) On 7/12/23 at 9:44 a.m. an interview was conducted with Staff N, Housekeeping Aide. She stated she had been at the facility for a year. She said, Yes, I have seen roaches, and ants. I just spray them away if they are in bathroom with my cleaning spray. She stated she notifies someone such her supervisor. Review of the Pest Sighting Log Sheet showed recent sightings as follows: 6/23/23 in room [ROOM NUMBER] B a pest was seen. There was no acknowledgement by staff of the pest sightings noted on the sheet. 6/25/23 in room [ROOM NUMBER] A multiple pests were seen. There was no acknowledgement by staff of the pest sightings noted on the sheet. There were no sightings reported after 6/25/23, until 7/10/23. 3. An observation on 07/10/2023 at 10:00 a.m., revealed Resident #60 sleeping in her bed with her mouth open and her covers partially pulled over her. Flies were seen flying around her mouth, on her face, and on her neck. A review of Resident #60's admission Record revealed she was admitted to the facility on [DATE], with diagnoses to include but not limited to major depressive disorder, and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. A review of the Quarterly Minimum Data Set (MDS), dated [DATE], Section C, Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) score of 99, indicating that Resident #60 was unable to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105998 If continuation sheet Page 31 of 32 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 07/13/2023 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 0925 complete the interview. Level of Harm - Minimal harm or potential for actual harm A review of the care plan initiated on 01/18/2022 and revised on 1/18/2022, showed that Resident #60 has an ADL (activities of daily living) self-care performance deficit related to (r/t) dementia. Further review showed an intervention initiated on 01/18/2022, showing that Resident #60 is totally dependent on one to two staff for repositioning and turning in bed as necessary and for dressing toileting and transferring. In addition, Resident #60 was totally dependent on one staff for eating. Residents Affected - Some 2. An observation on 7/10/23 at 9:53 a.m. of the 600-hall oxygen room revealed under an empty oxygen rack dirt and mulch-looking material and behind the door was piles of dead ants intermixed with dust. On 7/10/23 at 10:12 a.m., an observation was made of the bedside refrigerator in Resident room [ROOM NUMBER], inside the refrigerator was three dead bugs on the bottom and one on a door shelf. On 7/10/23 at 10:29 a.m., Staff R, Laundry Aide stated they only clean refrigerators in resident rooms if the resident requests, not supposed to go in their refrigerators. On 7/10/23 at 12:18 p.m., the exit door at the end of the 600-hall was framed with cobwebs that had dead ants in them. The door bar had dead ants lying on it and in the corners on each side of the hall was cobwebs with dead ants. (Photographic Evidence Obtained) On 7/10/23 at 2:25 p.m., an observation was made of the vanity top in the bathroom of Resident room [ROOM NUMBER]. The observation identified numerous dead ants next to the sink. On 7/13/23 at 12:39 p.m., a tour was conducted with the Housekeeping Manager. The tour included an observation of the bathroom for Resident room [ROOM NUMBER]. One of the resident's in the room stated, While you're in there step on the roaches. During the observation a live roach came out from the shower and moved towards the door. The Housekeeping Manager chased it back into the shower area and killed it. On 7/13/23 at 12:39 p.m., the Housekeeping Manager stated housekeeping staff were responsible for cleaning resident rooms, common areas, dining room, clean and soiled utility rooms, oxygen room, and all offices. The Housekeeping Manager reported the facility was fully staffed with 10 housekeeping staff. The Housekeeping Manager stated housekeeping staff were supposed to clean refrigerators inside resident rooms, the cobwebs at the end of the 600-hall were supposed to be cleaned daily, dead ants were to be cleaned off surfaces, the bugs inside Resident room [ROOM NUMBER]'s refrigerator should have been cleaned along with the toilet bases. A review of the policy titled, Resident Refrigerators, implemented 5/2022 and revised 2/2023, revealed: This facility does not provide a refrigerator in a resident's room. However, it the policy of this facility to ensure safe and sanitary use of any resident-owned refrigerators. The policy explanation and guidelines showed the dormitory-sized refrigerator are allowed in a resident's room under the following conditions, which included: the refrigerator is inspected by maintenance personnel and deemed safe prior to use and upon routine inspections, and identified that nursing/housekeeping staff shall clean the refrigerator and discard any foods that are out of compliance. The policy showed the Accommodations shall be made for the resident to be present for temperature checks, observing food for sanitary storage, and cleaning of the refrigerator, if so desired by the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105998 If continuation sheet Page 32 of 32