Inspection·October 30, 2020

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Staff A positioned the resident so she could have a window visit with her family member. Resident #99 could not hear her family member through the window and kept saying, I can't hear what you're saying. The family member, while outside and on the other side of the door window, pulled down her face mask and told Staff A that Resident #99 had a hearing aid and asked why it was not in her ear. Staff A was overheard telling Resident #99's family member that she was unaware that she had or needed a hearing aid. Staff A pulled out her personal cell phone from her pocket and dialed Resident #99's family member's cell phone so Resident #99 and her family member could talk via the telephone. It was observed that this did not work as Staff A sat the phone on one of the dining room tables, behind the resident, while she was in her wheelchair. The phone could be overheard on speaker, but the volume was not loud. Therefore, Resident #99 could not hear her family member talk. At that point Staff A and B, Activities Aide left and then went to Resident #99's room to find the hearing aid. They were gone from 1:25 p.m. and returned at 1:35 p.m. without a hearing aid. Resident #99 from 1:18 p.m. to 1:35 p.m. was observed upset and kept telling staff to let her family member in the door. When staff tried to tell her that her family member could not come inside, she kept asking what they were saying. The family member kept yelling through the door window that Resident #99 could read lips, but Staff A said that they could not remove or lower their masks for her to read their lips. Resident #99 continued to appear confused and upset. The visit with Resident #99 and her family member was ended at 1:36 p.m. because they were unable to communicate well due to her not having her hearing aid. Staff A removed Resident #99 from the dining area and assisted her back to her room, where Staff B was still in there looking for a hearing aid. Staff A confirmed that she cut the visit short because they (Resident #99 and family member) could not hear each other, even with using the telephones. Staff A and B both confirmed that Resident #99 has hearing loss and that the hearing aid could not be located. On 10/27/20 at 1:38 p.m. an interview with Staff D, Licensed Practical Nurse (LPN) confirmed that she observed the window visit between Resident #99 and her family member. Staff D was observed, from 1:18 p.m. to 1:36 p.m. standing approximately twenty feet away from where Resident #99 was positioned during the family window visit. During that time, she did not go over and offer any assistance, or try to communicate with Resident #99 for her family member. Review of the admission Record dated 10/7/2020 for Resident #99 revealed diagnoses to include dementia, anxiety, and unspecified hearing loss bilateral. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed there was no score for the Brief Interview for Mental Status and no indication of short-term memory, long term memory or decision-making skills. However, the assessment indicated that Resident #99 did not answer correctly the questions related to the current year, current month, or current week, and could not recall memory word. The Hearing/Speech/Vison section showed hearing checked as adequate, no hearing aid was checked. On 10/28/2020 at 12:03 p.m. a telephone interview was conducted with Resident #99's family member. She was asked how her visit went with Resident #99 the day before, on 10/27/2020. Resident #99's family member was very upset that she could not speak effectively with Resident #99 during the visit and that the facility had somehow lost her hearing aid and Resident #99 was not able to hear anything during the time she was there visiting. She confirmed that Resident #99 has a hearing problem and had two hearing aids. She expressed that the hospital lost one, and that Resident #99 was admitted to the nursing facility with the other. Resident #99's family member was very upset that the window visit did not go well, and is upset that Resident #99 was upset because she could not communicate effectively either with the phone that was provided and from staff not knowing or finding her hearing aid (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 2 of 20 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 106086 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/30/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Health and Rehabilitation Center 701 Overlook Dr SE Winter Haven, FL 33884 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 0550 to use during the visit. Level of Harm - Minimal harm or potential for actual harm On 10/30/2020 at 3:00 p.m. an interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) and they explained that the facility should ensure that there is effective communication during visitation between residents and visitors. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 3 of 20 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 106086 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/30/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Health and Rehabilitation Center 701 Overlook Dr SE Winter Haven, FL 33884 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and record review, the facility failed to accurately assess one resident (#99) upon admission to the facility for a communication deficit related to hearing loss out of a total sample of thirty-three residents. Findings included: Review of the admission Record dated 10/7/2020 for Resident #99 revealed diagnoses to include dementia, anxiety, and unspecified hearing loss bilateral. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed there was no score for the Brief Interview for Mental Status and no indication of short-term memory, long term memory or decision-making skills. However, the assessment indicated that Resident #99 did not answer correctly questions related to the current year, current month, current week, and could not recall memory word. The Hearing/Speech/Vison section showed hearing checked as adequate, no hearing aid was checked. During an observation on 10/27/2020 from 1:18 p.m. to 1:36 p.m. Staff A, Activities Aide assisted Resident #99, while seated in her wheelchair, out from her room, and to the 700-hall dining room exit door, to have a window visit with her family member. During that time, Resident #99 was noted to not be able to hear her family member who was on the other side of the exit door. Staff A, Activities Aide took out her cellular phone and dialed Resident #99's family member. However, Resident #99 kept telling Staff A that she could not hear. At this time, Resident #99's family member asked through the door window, Where is her hearing aid? The family member said, She has a hearing aid, please go to her room and look for it. Staff A and B, Activities Aide, had attempted to explain to Resident #99 that they could not let her family member in the room. Resident #99 kept saying she could not hear what they were saying and to let her family member in. Staff A and Staff B, Activities Aide were not able to locate the hearing aid. An interview on 10/27/2020 at 1:36 p.m. with Staff C, Certified Nursing Assistant (CNA), who was assigned to Resident #99 during the 7:00 a.m. to 3:00 p.m. shift, revealed that she was not aware that Resident #99 had a hearing aid. Staff C confirmed that Resident #99 had a hearing issue and did not hear well. Staff C stated that when communicating with Resident #99 while providing care and services that she had to speak loud and lean into one of Resident #99's ears. On 10/27/2020 at 1:37 p.m. an interview with Staff D, Licensed Practical Nurse (LPN) revealed that she had provided care and services to Resident #99. Staff D further revealed that she was unaware if Resident #99 had any hearing aids. Staff D had searched the room with the activities aides, Staff A and B, and also looked in her medication cart. Staff D, LPN could not find any hearing aids and could not find any documentation in the chart to show who would maintain them. Staff D was asked how she communicated with Resident #99, and she said that she had to lean in and talk loudly. Staff D confirmed that Resident #99 has hearing loss. Staff D confirmed that the visit between Resident #99 and her family member did not go well, because she (Resident #99) could not hear her family member. An initial review of Resident #99's active care plan on 10/27/2020 revealed that it was silent in regards to a communication deficit related to hearing loss. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 4 of 20 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 106086 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/30/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Health and Rehabilitation Center 701 Overlook Dr SE Winter Haven, FL 33884 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 10/28/2020 at 8:40 a.m. Resident #99 was observed in her room with the breakfast meal tray in front of her and she was seated in her wheelchair. An interview was attempted from the doorway by knocking loudly and waving to get Resident #99's attention. Resident #99 waved back and when asked how her meal was she did not respond. When asked again loudly, she indicated that she could not hear and pointed to her ear. On 10/28/2020 at 12:03 p.m. a telephone interview was conducted with Resident #99's family member. She confirmed that Resident #99 has a hearing problem and had two hearing aids. She expressed that the hospital lost one, and that Resident #99 was admitted to the nursing facility with the other. Resident #99's family member was very upset that the window visit did not go well, and is upset that Resident #99 was upset because she could not communicate effectively either with the phone that was provided and from staff not knowing or finding her hearing aid to use during the visit. On 10/28/2020 at 12:20 p.m. an interview with Staff E, Social Worker revealed that when residents are admitted to the facility the social service staff are responsible to assess and document the hearing and vision portions of the MDS assessment and routinely thereafter. Staff E revealed when he originally assessed Resident #99, around 10/7/2020, he thought that the lack of effective communication was due to her cognition and not her hearing. He added that he did not know she had a hearing deficit, nor did he know if she had a hearing aid to utilize. In addition, Staff F, Social Worker was present and confirmed that Resident #99 did have a hearing deficiency. On 10/29/2020 at 7:20 a.m., during a tour of the 700 hall, certified nursing assistants, Staff G, and H. were interviewed. Staff H, CNA said that Resident #99 is hard of hearing and that she needs to lean forward, close to her, and speak loudly. Staff H did confirm once speaking loudly and while close to her (Resident #99), that she could answer most of the asked questions. Staff G, CNA and Staff H, CNA were unaware if Resident #99 utilized a hearing aid. On 10/29/2020 at 7:25 a.m. an interview with Staff I, LPN confirmed that Resident #99 does not hear well. Staff I was asked if Resident #99 had a hearing aid and she said that she did not know. She was asked where she would find out if Resident #99 or any resident has and utilizes a hearing aid. She revealed that she would look in the orders (physician), Medication Administration Record and Treatment Administration Record. Review of Resident #99's current physician orders for October 2020 revealed an order for Podiatry, Dental, Audiology, Optometrist and Mental Health care as need (no directions specified for order) with an order date 10/7/2020. The MAR and TAR for October 2020 were silent related to Resident #99's hearing loss and hearing aid. On 10/29/2020 at 12:30 p.m. an interview was conducted with Staff J, Registered Nurse (RN)/MDS Coordinator, Staff K, LPN/MDS Coordinator and Staff L, LPN/MDS Coordinator. They confirmed that they are responsible for the completion of the MDS assessments and that when information is brought to them from various departments, they would document in that assessment. Staff J, RN confirmed that social services would be the department that is responsible for assessing hearing and vision. Staff J, RN, Staff K, LPN, and Staff L, LPN all confirmed that the admission Nursing assessment dated [DATE] did not reflect a hearing deficit. Staff J, RN, Staff K, LPN and Staff L, LPN also confirmed that the MDS admission Assessment, dated 10/11/2020, revealed that Resident #99 had adequate hearing and no use of a hearing aid. Staff J, RN and Staff K, LPN both indicated that they have seen and spoken to Resident #99 a couple of times since her admission and both agreed that she does have a hearing deficit, but were unsure if she had a hearing aid. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 5 of 20 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 106086 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/30/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Health and Rehabilitation Center 701 Overlook Dr SE Winter Haven, FL 33884 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 0636 Level of Harm - Minimal harm or potential for actual harm During this continued interview, Staff J, K and L all agreed that Resident #99 was not accurately assessed for hearing and communication upon admission and that the hearing section should have been marked to show Resident #99 had a hearing deficit and that a baseline care plan with interventions and goals should have been initiated to reflect communication deficit related to hearing loss. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 6 of 20 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 106086 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/30/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Health and Rehabilitation Center 701 Overlook Dr SE Winter Haven, FL 33884 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 interviews, record reviews, and review of facility policy, the facility failed to provide needed care and services in accordance with professional standards related to not providing a proper assessment upon discovery of a skin alteration for one (Resident #451) of three residents sampled for skin alterations. Residents Affected - Few Findings included: A review of Resident #451's admission Record revealed that Resident #451 was readmitted to the facility on [DATE] with diagnoses of atrial fibrillation, hypertension, and type 2 diabetes mellitus. A review of Resident #451's active care plan dated of 10/28/20 revealed that Resident #451 was able to engage in leisure on his own as well as make his needs known. Resident #451's care plan also revealed that Resident #451 had a risk for development of pressure ulcers related to decreased mobility and diabetes mellitus, with interventions to observe skin weekly and as needed, give incontinence care and apply barrier cream as needed, and turn and reposition frequently and as needed. An interview was conducted on 10/28/2020 at 8:27 AM with Resident #451. Resident #451 stated that he had an open area underneath of his testicles and that staff was giving him a cream to apply to the area. Resident #451 also stated that the area had developed over the last couple of days and that he had no pain or discomfort to the area at the time of the interview. Resident #451 was not able to state what kind of cream was being applied to the area at the time of the interview. An interview was conducted on 10/29/2020 at 4:14 PM with Staff T, Certified Nursing Assistant (CNA). Staff T CNA stated that Resident #451 had a rash on his testicles and that they were applying barrier cream to the area during incontinence care. Staff T, CNA also stated that Resident #451 told him about the area on 10/28/2020 and that she let the nurse know that day. Staff T, CNA stated that any time a new area is found on a resident's skin, she would tell the nurse. An interview was conducted on 10/29/2020 at 4:32 PM with Staff U, Licensed Practical Nurse (LPN). Staff U, LPN stated that she took care of Resident #451 about 2 or 3 days ago and could not recall if Resident #451 had any skin alterations. Staff U, LPN also stated that Resident #451 was able to make his needs known to staff. An interview was conducted on 10/30/2020 at 8:47 AM with Staff V, CNA. Staff V, CNA stated that she found out on 10/28/2020 at the beginning of her shift that Resident #451 had redness around his testicles and that they were applying A and D ointment to the area during incontinence care. A review of Resident #451's CNA Skin Observations revealed documentation from 10/24/2020 at 1:30 PM, which indicated a Red Area was observed by staff. The documentation also revealed that the Red Area observed on 10/24/2020 at 1:30 PM was not new. A review of Resident #451's CNA Skin Observations also revealed documentation from 10/28/2020 at 10:59 PM, which indicated a Red Area was observed by staff. The documentation also revealed that the Red Area observed on 10/28/2020 at 10:59 PM was not new. A review of Resident #451's Weekly Skin Observation, dated 10/23/2020 at 3:05 PM, revealed documentation of a skin assessment for Resident #451 and indicated that Resident #451 had no skin alterations. A review of Resident #451's Weekly Skin Observation, dated 10/29/2020 at 7:38 PM, revealed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 7 of 20 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 106086 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/30/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Health and Rehabilitation Center 701 Overlook Dr SE Winter Haven, FL 33884 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 documentation of a skin assessment for Resident #451 and indicated that Resident #451 had an intact, blanchable redness of posterior scrotal area. The documentation also revealed a new treatment to apply barrier cream to intact, blanchable redness on scrotal area and leave open to air, every shift for preventative skin care. A review of Resident #451's Physician's Orders for October 2020 revealed an order, dated 10/29/2020, to apply barrier cream to intact, blanchable redness on scrotal area and leave open to air, every shift for preventative skin care. An interview was conducted on 10/30/2020 at 11:59 AM with Staff W, LPN. Staff W, LPN stated that if a new skin alteration is discovered by staff during resident care, the nurse is to conduct an assessment of the area and contact the physician to obtain orders for treatment. Staff W, LPN also stated that he assessed Resident #451 that morning and observed redness to Resident #451's groin and buttocks area. Staff W, LPN stated that he was not aware of the area to Resident #451 and that he still needed to document the findings from the skin assessment he conducted, but he did not have time to complete the documentation yet. An interview was conducted on 10/30/2020 at 3:32 PM with the facility's Director of Nursing (DON). The DON stated that nursing staff were expected to monitor resident's skin frequently in order to identify any new concerns. If a CNA would observe a new skin alteration on a resident, they should tell the nurse and document the finding in the resident's electronic medical record. The nurse should then assess the area at that time and call the resident's physician to get treatment orders and also inform the resident's responsible party. The DON stated that she would expect to see a Change in Condition form or a Nurse's Note in the resident's electronic record documented by the nurse upon discovery of a new skin alteration. A review of the facility policy titled, Weekly Skin Observation, dated 02/2018, revealed that licensed nurses and CNAs would document all areas of abnormal skin and whether the area was new or old. The policy also revealed that new areas noted during the shower skin checks or weekly skin observations would require the licensed nurse to initiate a skin assessment using either an initial pressure or non-pressure assessment or a wound assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 8 of 20 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 106086 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/30/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Health and Rehabilitation Center 701 Overlook Dr SE Winter Haven, FL 33884 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that appropriate treatment and services to prevent urinary tract infections by not ensuring the tubing for an indwelling catheter was kept off of the floor for one resident (#99) of two residents sampled for two of two days. Findings included: On 10/27/2020 at 1:18 p.m. Resident #99 was observed seated in her wheelchair next to her bedside. The observation revealed the resident was utilizing an indwelling catheter, which was positioned under her seat. Approximately six inches of tubing was observed lying on the floor. Her left heel, which was in a red sock, was observed touching the tubing. An activities staff member, Staff A, was observed in the room assisting the resident while seated in her wheelchair. She transferred the resident from her room down the hall approximately fifty feet to the 700- hall dining room exit door. The indwelling catheter tubing was observed dragging on the carpeted floor from the room to the dining room. While seated in her wheelchair, Resident #99 was continuously rocking back and forth using her feet, and consequently stepping on the catheter tubing with the back of her left heel. Staff A, at 1:36 p.m., was observed to remove Resident #99 from the family window visit in the 700-hall dining room and proceeded to push the resident, while seated in her wheelchair, back to her room, approximately fifty feet. During the transfer, the catheter tubing was observed dragging on the floor beneath Resident #99's wheelchair. An interview with Staff A, following this observation, revealed that she was new to the facility and did not know to look for placement of the catheter tubing, and did not know it was dragging on the ground until it was brought to her attention. She did not know who to talk to other than maybe the nurse to let her know it was on the floor. On 10/27/20 at 1:38 p.m. an interview with Staff C, CNA confirmed that she was the aide on the 700 hall during the 7:00 a.m. to 3:00 p.m. shift and had Resident #99 on her assignment. She confirmed that the catheter tubing was lying on the ground from excessive slack. Staff C continued to say that she was new on the unit and does not know Resident #99 well and didn't really know much about the catheter. She was asked if she provided any activities of daily living care to Resident #99 today and she said that she did. She still said she was not sure about the use of the indwelling catheter, and that she was new on this hall. She was then asked who would correct the positioning of the tubing. Staff C did not answer and went to get the nurse. On 10/27/20 at 1:39 p.m. an interview was conducted with Staff D, Licensed Practical Nurse (LPN). She was observed to go in Resident #99's room and Staff C, CNA showed her that the catheter tubing was lying on the floor with excessive slack. Staff D confirmed that the tubing needed to be repositioned and closed the door to readjust it. On 10/28/2020 at 2:20 p.m., Resident #99 was observed in her room and was seated in her wheelchair between the side of the bed and the door wall. She was noted to be repeatedly rocking back and forth in the wheelchair with her feet touching the floor. The wheelchair was observed to rock about six inches forward, and then six inches back. While rocking back in forth in the wheelchair, she was observed stepping on her indwelling catheter tubing with the heels of both feet. About five inches of the catheter tubing was dragging/lying on the floor beneath her. Further observation revealed the indwelling catheter bag was observed dragging/lying on the floor under her. The corner side of the bag (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 9 of 20 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 106086 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/30/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Health and Rehabilitation Center 701 Overlook Dr SE Winter Haven, FL 33884 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was being ran over repeatedly with the left tire. An interview was attempted with the resident and she did not answer. On 10/28/20 at 2:23 p.m. an interview was conducted with the 700- floor nurse, Staff D, LPN. Staff D confirmed the tubing was on the floor and that the catheter bag was dragging on the floor as well. She was asked if she was made aware of the observation on 10/27/2020 of the tubing dragging on the floor and if the resident had a behavior of pulling it out. She confirmed that she was made aware of it and that she was unaware of the resident having behaviors, and also indicated that both the bag and the tubing should be up off the floor and in a manner that is free from kinks and hazards. Review of Resident #99's admission Record revealed that she was admitted to the facility on [DATE] for long term care services and revealed diagnoses to include dementia and urinary retention. Review of the Admission/Readmission/Evaluation dated 10/7/2020 revealed diagnoses to include urinary tract infection and yes was checked for catheter. Review of the admission Minimum Data Set (MDS) assessment, dated 10/11/2020, revealed the resident used an indwelling catheter. Review of the current care plan with an initiated date of 10/8/20 revealed a focus area for an indwelling catheter related to urinary retention. Interventions included catheter care each shift, and privacy covering on drainage bag. On 10/30/2020 at 1:30 p.m. the Nursing Home Administrator provided the Catheter Use Care Policy and Procedure, with a last revision date of 11/2019. The policy revealed, It is the policy of this facility to ensure that a resident that enters this facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary; or A resident that enters the facility with an indwelling catheter is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates catheterization is necessary; and provide proper care while a resident is catheterized including observing for signs of catheter related to infections. Under the General Considerations: section of the policy revealed under #2. Catheter care will include cleansing the perineal area and the external portion of the catheter, draining the collection bag, and placing the tubing and collection bag in correct position to prevent infection, as well as provide dignity to the resident; #4. Staff should check the tubing frequently throughout the shift to ensure that: a. the resident is not lying on the tubing, b. that the tubing is looped and secured, and c. the tubing is free from kinks; and #6. The drainage bag and tubing should not touch the floor at any time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 10 of 20 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 106086 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/30/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Health and Rehabilitation Center 701 Overlook Dr SE Winter Haven, FL 33884 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure pain management was provided in accordance with the care plan for one resident (Resident #453) of one resident sampled for pain management. Residents Affected - Few Findings included: An interview was conducted on 10/27/2020 at 10:49 AM with Resident #453. Resident #453 stated that she had a fall at home prior to admission and that she experienced pain in her left arm. Resident #453 stated that she experienced pain in her left arm and along the left side of her neck often but was not able to state if she received any pain medication. A review of Resident #453's admission Record revealed that Resident #453 was admitted to the facility on [DATE] with diagnoses of dementia, urinary tract infection (UTI), history of falling, and cognitive communication deficit. A review of Resident #453's current care plan revealed that Resident #453 had acute pain related to UTI, with interventions for the resident to request pain medication as needed and staff to observe to determine if the resident was having non-verbal signs of pain. A review of Resident #453's physician's orders for October 2020 revealed an order, dated on 10/27/2020, for Tylenol Extra Strength 500 milligrams (mg) by mouth twice daily as needed for non-acute pain. Resident #453's physician's orders did not reveal an order for pain monitoring. A follow up interview was conducted on 10/28/2020 at 8:19 AM with Resident #453. Resident #453 stated that she was having pain on the right side of her neck and that she asked the staff for pain medication, but nobody ever came to administer the medication. Staff V, Certified Nursing Assistant(CNA) was observed outside of the room and stated that she let the nurse know that Resident #453 needed pain medication. A review of Resident #453's Medication Administration Record (MAR) for October 2020 revealed documented administration of Tylenol Extra Strength 500 mg by mouth on 10/28/2020 at 10:33 AM with a documented pain level of 6. No additional pain level documentation was revealed on Resident #453's MAR. An interview was conducted on 10/29/2020 at 5:08 PM with Staff X, Registered Nurse (RN) Risk Manager, who stated that she was also the acting Assistant Director of Nursing. Staff X, RN stated that nurse's should be documenting on resident's pain level daily in the Skilled Charting notes and that pain levels for residents should be documented every shift. A review of Resident #453's Progress Notes revealed that Daily Skilled Progress Notes were not completed on 10/27/2020, 10/28/2020, or 10/29/2020. A telephone interview was conducted on 10/30/2020 at 11:04 AM with the facility's Consultant Pharmacist, who stated that she would expect to see pain monitoring being completed on every shift for any resident that was receiving pain medication. An interview was conducted on 10/30/2020 at 11:36 AM with Staff W, Licensed Practical Nurse (LPN). Staff W, LPN stated that pain monitoring for residents automatically comes up in the resident's MAR (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 11 of 20 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 106086 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/30/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Health and Rehabilitation Center 701 Overlook Dr SE Winter Haven, FL 33884 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 0697 Level of Harm - Minimal harm or potential for actual harm when a pain medication is put into the electronic record. Pain monitoring was documented only when a resident requested pain medication for a resident that was alert and oriented. Staff W, LPN stated that Resident #453 was alert and oriented and was able to make her needs known to staff. Staff W, LPN was not able to state why a Skilled Progress Note was not completed on 10/27/2020, 10/28/2020, or 10/29/2020, but stated that the 3 PM to 11 PM shift was responsible for completing the note daily. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 12 of 20 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 106086 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/30/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Health and Rehabilitation Center 701 Overlook Dr SE Winter Haven, FL 33884 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, interviews, record reviews, and review of facility policy, the facility failed to ensure a medication error rate of less than 5 percent. Three (3) medication errors were identified out of 26 opportunities while conducting medication administration observation for 1 (Resident #50) out of 6 residents sampled. The facility medication error rate was 11.5 percent. Residents Affected - Few Findings included: An observation was conducted on 10/29/2020 at 09:35 AM of medication administration with Staff Y, Licensed Practical Nurse (LPN). Staff Y was observed preparing the following medications for administration to Resident #50: - Prostat liquid 30 milliliters (ml) - Eliquis 5 milligrams (mg) 1 tablet - Aspirin 81 mg 1 tablet - Vitamin C 500 mg 1 tablet - Metoprolol 25 mg 1/2 tablet - Guaifenesin ER 600 mg 1 tablet - Multivitamins with minerals 1 tablet - Flomax 0.4 mg 1 tablet - Zinc 1 tablet. No dosage on label - Guaifenesin ER 600 mg 1 additional tablet. Staff Y, LPN stated that Resident #50 had a duplicate order for Guaifenesin ER 600 mg and stated that she needed to administer an additional tablet. After preparing the medications for Resident #50, Staff Y, LPN performed hand hygiene and prepared to enter Resident #50's room for medication administration. Staff Y, LPN was asked to verify the medication orders for Resident #50 before administering the medications. A review of Resident #50's Physician's Orders revealed the following orders: - Prostat liquid 30 ml by mouth once daily at 09:00 AM - Eliquis 5 mg 1 tablet by mouth twice daily at 09:00 AM and 05:00 PM - Aspirin 81 mg 1 tablet by mouth once daily at 09:00 AM - Vitamin C 500 mg 1 tablet by mouth twice daily at 09:00 AM and 05:00 PM - Metoprolol 25 mg 1/2 tablet by mouth twice daily at 09:00 AM and 05:00 PM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 13 of 20 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 106086 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/30/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Health and Rehabilitation Center 701 Overlook Dr SE Winter Haven, FL 33884 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 - Guaifenesin ER 600 mg 1 tablet by mouth twice daily at 09:00 AM and 09:00 PM Level of Harm - Minimal harm or potential for actual harm - Multivitamins with minerals 1 tablet by mouth once daily at 09:00 AM - Flomax 0.4 mg 1 tablet by mouth once daily at 09:00 AM Residents Affected - Few - Zinc 100 mg 1 tablet by mouth twice daily at 09:00 AM and 05:00 PM - Fexofenadine Hydrochloride (HCl) 2 tablets by mouth twice a day at 09:00 AM and 05:00 PM - There was no order for Guaifenesin ER 600 mg 1 additional tablet. Staff Y, LPN was going to administer an unknown dose of Zinc tablet and an extra dose of Guaifenesin ER 600 mg prior to reviewing Resident #50's Physician's Orders. After verifying Resident #50's orders, Staff Y, LPN removed the bottle of Zinc from the medication cart and observed that there was no dosage on the bottle. Staff Y, LPN addressed that she did not verify the dosage of Zinc before preparing it for administration to Resident #50 and could have administered the wrong dose. Staff Y, LPN prepared 2 tablets of Zinc 50 mg to administer to Resident #50. Staff Y, LPN attempted to find Fexofenadine HCl for administration to Resident #50 and pulled out the box of Guaifenesin ER 600 mg to verify the medication. Staff Y, LPN then asked isn't that the same drug?. Staff Y, LPN then stated maybe I made a mistake and attempted to locate Fexofenadine HCl in the medication room. Staff Y, LPN returned to the medication cart and stated that she was not able to find Fexofenadine HCl in the medication room. Staff Y, LPN stated that she would order the correct medication from the pharmacy and marked the medication in Resident #50's medication administration record as not available. Staff Y, LPN administered the following medications to Resident #50: - Prostat liquid 30 ml - Eliquis 5 milligrams mg 1 tablet - Aspirin 81 mg 1 tablet - Vitamin C 500 mg 1 tablet - Metoprolol 25 mg 1/2 tablet - Guaifenesin ER 600 mg 1 tablet - Multivitamins with minerals 1 tablet - Flomax 0.4 mg 1 tablet - Zinc 50 mg 2 tablets Resident 50 did not receive his 9:00 am dose of Fexofenadine Hydrochloride (HCl) 2 tablets. Following the medication administration observation, an interview was conducted with Staff Y, LPN. Staff Y, LPN stated she has had training regarding the five rights of medication administration and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 14 of 20 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 106086 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/30/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Health and Rehabilitation Center 701 Overlook Dr SE Winter Haven, FL 33884 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few that she would normally verify for the correct medication and the correct dosage before administering a medication. An interview was conducted on 10/30/2020 at 03:23 PM with the facility's Director of Nursing (DON). The DON stated that staff should be trained in the five rights of medication administration and that nurse's should verify the right dosage, right resident, right route, right medication, and right time 3 times before administering a medication. A review of the facility policy titled Medication Administration, revised on February 2020, revealed under the section titled Procedure for licensed staff to follow the six rights of medication administration: 1. Right Medication 2. Right Dose 3. Right patient 4. Right route 5. Right time 6. Right documentation FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 15 of 20 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 106086 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/30/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Health and Rehabilitation Center 701 Overlook Dr SE Winter Haven, FL 33884 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed ensure one (Resident #453), of three residents sampled for Urinary Tract infections, received the correct dose and amount of antibiotic as prescribed. Residents Affected - Few Findings included: A review of Resident #453's medical record revealed that Resident #453 was admitted to the facility on [DATE] with diagnoses of dementia, urinary tract infection (UTI), history of falling, and cognitive communication deficit. A review of Resident #453's Care Plan revealed that Resident #453 had an acute UTI, with interventions to administer antibiotics as ordered, obtain urinalysis and culture and sensitivity as ordered, and observe for and document signs and symptoms of UTI. Resident #453's Care Plan also revealed that Resident #453 had acute pain related to UTI, with interventions for resident to request pain medication as needed and staff to observe to determine if resident was having non-verbal signs of pain. A review of Resident #453's Medication Discharge Report, dated on 10/23/2020, revealed an order for ciprofloxacin (Cipro - an antibiotic) 500 milligrams (mg) by mouth every 12 hours (a total of 2 doses per day or 1000 mg per day) for 3 days (a total of six doses for three days). A review of Resident #453's Physician's Orders revealed an order, dated on 10/24/2020, for Cipro 500 mg by mouth every 12 hours for 3 days for diagnosis of UTI, discontinued on 10/26/2020. Resident #453's Physician's Orders also revealed an order, dated on 10/25/2020, for Cipro 500 mg by mouth every 12 hours for 3 days for diagnosis of UTI, discontinued on 10/27/2020. A review of Resident #453's Medication Administration Record (MAR) revealed the following administration documentation for Cipro 500 mg by mouth: - 10/24/2020 at 09:00 PM - 10/25/2020 at 06:00 AM,09:00 AM, 06:00 PM, and 09:00 PM (total of 2000 mg in a day, twice as much as prescribed) - 10/26/2020 at 06:00 AM,09:00 AM, and 06:00 PM (total of 1500 mg in a day, 500 mg more than prescribed) - 10/27/2020 at 06:00 AM and 06:00 PM Resident #453 received a total of 10 doses of Cipro 500 mg by mouth from 10/24/2020 through 10/27/2020. An interview was conducted on 10/29/2020 at 04:32 PM with Staff U, Licensed Practical Nurse (LPN). Staff U, LPN reviewed Resident #453's MAR and stated Resident #453 had duplicate orders for Cipro 500 mg by mouth. Staff U, LPN stated she administered the dose on 10/27/2020 at 06:00 PM. Staff U, LPN also stated that Resident #453 had been administered Cipro 500 mg by mouth more than twice a day and that was a medication error. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 16 of 20 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 106086 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/30/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Health and Rehabilitation Center 701 Overlook Dr SE Winter Haven, FL 33884 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 0760 Level of Harm - Minimal harm or potential for actual harm An interview was conducted on 10/29/2020 at 05:08 PM with Staff X, Registered Nurse (RN) Risk Manager, who stated that she was also the acting Assistant Director of Nursing. Staff X, RN stated that she reviewed Resident #453's chart on 10/26/2020 and discontinued the duplicate order for Cipro 500 mg by mouth . Staff X, RN stated that Resident #453's MAR documented that Cipro 500 mg by mouth was administered multiple times and stated that it was a medication error. Residents Affected - Few A telephone interview was conducted on 10/30/2020 at 11:04 AM with the facility's Consultant Pharmacist who stated that administering additional doses of Cipro 500 mg by mouth more than prescribed would be considered a significant medication error due to the risk of gastrointestinal side effects. The Consultant Pharmacist also stated that Cipro 500 mg is never dosed for 4 times a day and that there would be no good reason to administer that many doses in one day. An interview was conducted on 10/30/20 at 03:23 PM with the facility's Director of Nursing (DON). The DON stated that if nursing staff noticed a duplicate order for a medication, the physician should have been notified in order to get clarification. The DON also stated she expected the nursing staff to mark the order as a duplicate order by making a note in the electronic administration record and not documenting it as administered unless the medication was administered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 17 of 20 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 106086 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/30/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Health and Rehabilitation Center 701 Overlook Dr SE Winter Haven, FL 33884 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, record review, and interviews the facility did not ensure that one opened insulin pen and two insulin vials were labeled with the date opened or the expiration date in one medication storage cart (700 Hallway) of the three medication storage carts sampled during the performance of the facility task of Medication Storage and Labeling. Findings included: On 10/30/2020 at 11:50 AM Staff I, Licensed Practical Nurse (LPN) accommodated the observation of the locked medication storage cart for the 700 Hallway. Staff I, LPN unlocked the cart and opened the first drawer which revealed one insulin pen that was opened and not dated, and two insulin vials that were opened and not dated (Photographic Evidence Obtained). Staff I, LPN confirmed that the insulin pen and vials were opened and not dated with an open date. She confirmed they should have been dated when opened because they expire after 28 days, Staff I, LPN stated that she did not know why the insulin pen and vials were not dated. Staff I, LPN stated that the nurse who opened them should have dated them. A telephone interview with the Pharmacist Consultant occurred on 10/30/2020 at 1:10 PM. The Pharmacist Consultant confirmed that nurses are to fill in the date opened sticker on the insulin pen and on the insulin vial when they are first opened. She further stated that insulin vials are kept for 28 days after being opened and that the nurses are trained on the need for the opened on date in order to ensure the medication is safe to use. She further stated that the Tresiba insulin pen also needs to be dated, but that it has a longer expiration. Review of the facility's policy entitled, Guidelines for Medication Storage and Labeling, with a revision date of 07/20 was conducted and revealed under General Guidelines Section 9. Multi-dose vials that have been opened or accessed (e.g. needle punctured) should be dated when the vial is first accessed and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. An interview with the Director of Nursing (DON) and Nursing Home Administrator was conducted on 10/30/20 at 3:30 PM. During the interview, the DON stated that nurses are regularly trained, according to the facility's policy, to date an insulin pen or an insulin vial when it is first opened, and confirmed that it was her expectation that the insulin pens and insulin vials that have been opened would have the opened on sticker filled in with that date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 18 of 20 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 106086 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/30/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Health and Rehabilitation Center 701 Overlook Dr SE Winter Haven, FL 33884 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and policy review, the facility failed to provide influenza and pneumococcal vaccination documentation related to consent and administration of influenza vaccinations for three (Resident #26, Resident #99, and Resident #47) of five residents sampled for influenza vaccinations, and failed to provide documentation related to consent and administration of pneumococcal vaccination for two (Resident #99 and Resident #47) of five residents sampled for pneumococcal vaccination. Residents Affected - Few Findings included: A review of the facility policy titled, Influenza/Pneumococcal Vaccine, with a revision date of 09/2019, revealed that all residents and employees who have direct contact with residents will be offered influenza vaccine annually to encourage and promote benefits associated with vaccinations against influenza/pneumococcal. The facility shall provide pertinent information about the significant risks and benefits of vaccines to residents (or resident's legal representative); for example, risk factors that have been identified for specific age groups or individuals with risk factors such as allergies or pregnancy. The policy also revealed the following information under the section titled Policy Interpretation: - Prior to influenza vaccination, the resident (or resident's legal representative) will be provided with information and education regarding the benefits and potential side effects of the influenza vaccination. - For those receiving the influenza vaccine, the date of the vaccination, lot number, expiration date, person administering, and the site of the vaccination will be documented in the resident's medical record. - A resident's refusal of the vaccination shall be documented in the resident's medical record. - Residents that have not received the pneumococcal vaccines will be offered the vaccines upon admission. - Residents receiving the pneumococcal vaccination will be provided with education on the risks and benefits of the vaccination. - Residents receiving the pneumococcal vaccination will have the date of the vaccination, lot number, expiration date, person administering, and the site of the vaccination will be documented in the resident's medical record. The policy also revealed, under the section titled, Procedure, that if residents refuse a vaccine on their consent forms, they will be given the opportunity every year to receive a vaccine. An interview was conducted on 10/29/20 at 12:35 p.m. with the facility's Director of Nursing (DON). Information was requested from the DON related to influenza and pneumococcal vaccination education, consent/refusal, and proof of administration for Residents #26, #99, #47. The DON provided the following documentation for review on 10/30/20 at 12:40 p.m. : (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 19 of 20 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 106086 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/30/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Health and Rehabilitation Center 701 Overlook Dr SE Winter Haven, FL 33884 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 0883 Level of Harm - Minimal harm or potential for actual harm - Electronic consent for influenza vaccination for Resident #26, dated 7/8/2020. No documentation of influenza vaccination being administer was provided. No evidence of education regarding influenza vaccination being provided to Resident #26. Consent and education documentation for pneumococcal vaccination for Resident #26, dated 09/18/2018. No documentation of pneumococcal vaccination being administer was provided. Residents Affected - Few A review of Resident #26's medical record revealed that Resident #26 was admitted to the facility on [DATE]. - Documentation of influenza vaccination administration, dated 10/26/2020, was provided for Resident #47. No documentation of consent/refusal or education regarding influenza and pneumococcal vaccinations were provided. No proof of pneumococcal vaccination administration was provided for Resident #47. A review of Resident #47's medical record revealed that Resident #47 was admitted to the facility on [DATE]. - No documentation related to influenza and pneumococcal vaccination education, consent/refusal, or proof of administration was provided for Resident #99 A review of Resident #99's medical record revealed that Resident #99 was admitted to the facility on [DATE]. A follow up interview was conducted on 10/30/20 at 12:40 p.m. with the DON. The DON stated that the Admissions Director sends out consents for influenza and pneumococcal vaccinations upon admission to the facility for residents that are alert and oriented and are able to sign the consent themselves for vaccination. The DON stated that some of the consents are documented electronically in the electronic medical record and that some of the consents are mailed out, and resident representatives sign them and return them. The DON was not able to state who followed up to ensure vaccination documentation was obtained for residents. The DON stated that she would provide further documentation of vaccination status for the sampled residents and addressed that the documentation was requested on 10/29/2020 at 12:35 p.m. The DON did not provide further documentation for the sampled residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 20 of 20