Inspection·February 4, 2022

F 0622 another nursing home that wanted information. SS worker stated she will send it over. Level of Harm - Minimal harm or potential for actual harm [DATE] 3:34 PM daughter requested for information to be sent to two other nursing homes for LTC. Paper work was faxed as requested. SS will continue to follow up with family as needed. Residents Affected - Few [DATE] 3:05 PM SS worker faxed paper work to two additional nursing homes. Family not able to meet his needs at home. SS will continue to follow up with facilities and family as needed. [DATE] 9:06 AM Another nursing home called the facility. They can accept the resident today. They will set up transport and call SS worker back with a time. Family aware and pleased he will be able to stay at the new facility for long term care. Family was given the address and phone number. Resident assisted with packing his belongings. Review of the Census tab in the electronic medical record showed Resident #420 was originally admitted to a private room on [DATE]. On [DATE] he was moved to a semi-private room where he remained until he was discharged on [DATE]. Both of these rooms were certified for Medicare only. On [DATE] at 10:19 AM, the Director of Therapy said Resident #420 was evaluated on [DATE] by PT (physical therapy) and ST (speech therapy), and on [DATE] by OT (occupational therapy). He was discharged from therapy services on [DATE] after being on caseload for a couple weeks. He was wheelchair bound prior to therapy and had a poor prognosis. He was receiving help at home for self care before he was admitted . He was discharged form therapy [DATE] due to very low motivation. They would get him up in the chair and within ten minutes he was asking to go back to bed. With the low motivation, there wasn't really anything that could be done. Therapy recommended long term care. On [DATE] at 12:26 PM, the Social Services (SS) Assistant stated the resident was being discharged today to another nursing home in Lake [NAME]. He needed a long term care bed, and they accepted him. She reported that this facility did not have a long term bed available and once he was cut from therapy, he needed a long term care bed for Medicaid. She reported that the resident was currently in a skilled bed. A review of the daily census dated [DATE] provided by the Nursing Home Administrator (NHA), reflected there were 132 in the facility, 61 of the beds were certified for Medicare only and 71 were dually certified for Medicare and Medicaid. The [DATE] daily census indicating there were nine unoccupied beds, and five of these empty beds were dually certified. On [DATE] at 1:41 PM, the NHA said the empty beds on the Medicare/Medicaid halls were bed holds. He continued on to state that one resident expired that day and another one went to the hospital. A request was made for evidence of these bed holds. On [DATE] at 2:03 PM, a follow up interview with the NHA revealed he did not have evidence of the bed holds to provide to the surveyor. The NHA reported when someone was admitted , the facility lets them know based on the living will and therapy assessment, if we determine they need long term care. At that time, we look to see if we have a bed for long term care. This resident went to the hospital (on [DATE]) and another nursing home was supposed to take him but didn't have a bed at the time. We said we would take him while he was waiting for the long term bed. We had a bed but it was only female. [Hospital Name] called and asked about discharging him if I know he needs long term care. I told her we didn't discharge him. He had a discharge date . From there I let her know we would help depending on when he comes back. The daughter was irate and was in here yelling at social services. I (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 2 of 12 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 02/04/2022 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 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few explained to her we were not discharging him. We would make sure he had a place to go. She said we knew we didn't have a bed and didn't tell her that from the beginning. On [DATE] at 2:26 PM, another interview was conducted with the SS assistant. She said, they didn't want him to go to [NAME] City. He got accepted in Lake [NAME]. We have been making referrals since last week. They were happy and the daughter thanked me. We didn't have a long term care bed. That is a skilled private pay bed. He is on Medicaid. He can't afford it. It's three hundred something a day. On [DATE] at 8:35 AM, an interview was conducted with the Business Office Manager (BOM) and Business Office Assistant (BOA). The BOM said the NHA would be responsible to issue a thirty day notice. The BOA said the business office would provide billing statements. It's a combination of the business office, social services, and administration. It's a combination of all of us. If it's a Medicaid patient they have to have a Medicaid certified bed. At 8:48 AM on [DATE], an interview was conducted with the Admissions Director. She said the nurse liaison goes to the hospital and does an assessment on the patients prior to admission. He does a nurse to nurse over the phone if he can't see them in person. Then we coordinate with the case manager. We don't take residents with tracheotomies, medication administration of daptomycin, or oxygen administration over five liters. We typically only try to bring residents in if they have rehab potential, unless there is a plan that we are aware of. Typically we try to bring them in for rehab. Occasionally the hospital will call and ask if we have a bed. We just make sure they are good with the business office, have a Medicaid application, don't have any behaviors, and talk to the family to make sure they are going to settle in good. We make sure we are all on the same page and get some medical records form their physician. They can stay if we have the availability. Social services works with the family to find alternate placement for them if we don't have availability. All our beds aren't dually certified so we need to have an open bed on the long term care halls. We can clearly see if a bed is open every morning. We do about thirty admissions a week, depending on the week. On [DATE] at 8:57 AM, another interview was conducted with the NHA. He said, We have to notify families if there is an internal transfer, a bed hold policy if they are sent out. Notify the family of the transfer and bed hold policy. We wouldn't provide a thirty day notice and we would hold on to them and help them find placement. Usually we find safe placement for them. We evaluate them and give them a planned discharge date . You get priority if you're in the building already. They are priority. But if we don't have a bed we try to help with placement in another facility. We would issue a thirty day notice if we couldn't care for you or meet your needs. When they send them to the hospital, they should have them sign the bed hold policy. We have never not had anyone come back. We have never issued a thirty day notice. They have not been issued a transfer form. We have identified it. There's clearly a communication issue. The NHA stated, The two males (beds) we had were on our Covid unit and the two that passed away were women. The NHA did not know if they had a bed available on [DATE], the day Resident #420 was discharged . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 3 of 12 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 02/04/2022 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. A review of the admission record for Resident #81 revealed an original admission date of 12/9/21 and a most recent admission date of 12/23/21. The admission record revealed the most recent hospital stay was 12/15/21 through 12/23/21. Review of a SNF/NF (skilled nursing facility/nursing facility) to Hospital Transfer Form revealed Resident #81 was sent to the hospital on [DATE]. Continued review of the record revealed no evidence that the resident/responsible party received written notice of the hospital transfer. In addition, there was no evidence in the record to indicate the Long Term Care Ombudsman's office was notified of the hospital transfer. 4. A review of the admission record for Resident #420 revealed an admission date of 1/14/22. A review of the eInteract Transfer Form dated 1/27/22 reflected an unplanned transfer for chest pain. Continued review of the record revealed no evidence that the resident/responsible party received written notice of the hospital transfer. In addition, there was no evidence in the record to indicate the Long Term Care Ombudsman's office was notified of the hospital transfer. On 2/04/22 at 8:57 AM, the Nursing Home Administrator stated, We have to notify families if there is an internal transfer, a bed hold policy, if they are sent out. Notify the family of the transfer and bed hold policy. We wouldn't provide a thirty day notice and we would hold on to them and help them find placement. Usually we find safe placement for them. We evaluate them and give them a planned discharge date . You get priority if you're in the building already. They are priority. But if we don't have a bed we try to help with placement in another facility. We would issue a thirty day notice if we couldn't care for you or meet your needs. We have never not had anyone come back. We have never issued a thirty day notice. They have not been issued a transfer form. We have identified it. There's clearly a communication issue. Based on interviews and record reviews, the facility failed to provide written notification of Transfer/Discharge to Resident Representatives and failed to notify the Office of the State Long-Term Care Ombudsman of a resident transfer for four (Resident #420, Resident #81, Resident #66, and Resident #114) of five residents sampled for hospitalizations. Findings included: 1. A review of Resident #66's Medical Record revealed that Resident #66 was admitted to the facility on [DATE] with diagnoses of cellulitis of the face and need for assistance with personal care. A review of Resident #66's Progress Notes, dated 10/19/2021 at 04:54 PM, revealed that Resident #66 was sent to the hospital on [DATE] due to a possible stroke. Resident #66's Progress Notes also revealed a note, dated 12/05/2021 at 07:42 AM, which documented that Resident #66 was sent to the hospital on [DATE] due to swelling and redness on the right side of his face. 2. A review of Resident #114's Medical Record revealed that Resident #114 was admitted to the facility on [DATE] with diagnoses of acute appendicitis with perforation, abscess of liver, and sepsis. A review of Resident #114's Progress Notes, dated 12/09/2021 at 12:51 PM, revealed that Resident #114 was sent to the hospital on [DATE] due to poor oral intake and poor participation in therapies. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 4 of 12 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 02/04/2022 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 02/02/2022 at 2:51 PM, a request for Resident #66's Transfer/Discharge Notices on 10/19/2021 and 12/05/2021, and a request for Resident #114's Transfer/Discharge Notice on 12/09/2021 was made to the facility's Director of Nursing (DON). An interview was conducted on 02/02/2022 at 04:28 PM with the facility's Nursing Home Administrator (NHA). The NHA stated that they were aware that they were required to send notification of transfers to the Office of the State Long-Term Care Ombudsman within five business days, but it was not being completed as required. The Transfer/Discharge notices of residents that were being discharge to another facility were being communicated to the Long-Term Care Ombudsman every thirty days, but hospital transfers were not being communicated to the Long-Term Care Ombudsman. An interview was conducted on 02/03/2022 at 08:35 AM with the DON. The DON stated that the Transfer/Discharge notices were not being completed and the facility was not sending notification to the Long-Term Care Ombudsman as required. Nursing staff should be sending the Transfer/Discharge notices with the resident upon transfer to the hospital and the resident's representative should be notified. An interview was conducted on 02/04/2022 at 10:26 AM with Staff C, Social Services (SS). Staff C, SS stated that the Office of the State Long-Term Care Ombudsman was notified by her of any transfers to another facility, such as assisted living or another nursing home, but not upon transfers to the hospital. Staff C, SS stated that Staff D, Licensed Practical Nurse (LPN) was responsible for making the notifications to the Long-Term Care Ombudsman upon resident transfers to the hospital. An interview was conducted on 02/04/2022 at 10:40 AM with Staff D, LPN. Staff D, LPN stated that he was not responsible for sending Transfer/Discharge notices to the Office of the State Long-Term Care Ombudsman and that nobody relayed to him that he was responsible for making the notices. A review of the facility policy titled Notice of Transfer or Discharge, revised in June 2021, revealed under the section titled Responsible that Social Services/Designee and NHA were responsible for the process. The policy also revealed the following under the section titled Procedure: - In emergency transfers that are not resident-initiated, the nurse will complete the state approved form with reason(s) for the transfer in a language the resident can understand. - The nursing facility must place a copy of the notice in the resident's medical record and transmit/provide a copy to the resident/resident representative, a family member of the resident if known, the resident's legal representative if known, and the Long-Term Care Ombudsman program for any facility-initiated transfer, including but not limited to, emergency transfers to a hospital that has not been requested by the resident and/or resident representative. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 5 of 12 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 02/04/2022 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. A review of the admission record for Resident #420 revealed an admission date of 1/14/22. A review of the eInteract Transfer Form dated 1/27/22 reflected an unplanned transfer for chest pain. Continued review of the record revealed no evidence that the resident/responsible party received a bed hold notice upon transfer to the hospital. 4. A review of the admission record for Resident #81 revealed an original admission date of 12/9/21 and a most recent admission date of 12/23/21. The admission record revealed the most recent hospital stay was 12/15/21 through 12/23/21. Review of a SNF/NF (skilled nursing facility/nursing facility) to Hospital Transfer Form revealed Resident #81 was sent to the hospital on [DATE]. Continued review of the record revealed no evidence that the resident/responsible party received a written bed hold notice upon transfer to the hospital. On 2/03/22 at 9:57 AM, the DON confirmed the bed hold notice wasn't being sent. The policy says we are supposed to send them. But we never don't allow them back. They don't want to hold the bed most of the time. On 2/04/22 at 8:57 AM, an interview was conducted with the Nursing Home Administrator. He said We have to notify families if there is an internal transfer, a bed hold policy, if they are sent out. Notify the family of the transfer and bed hold policy. We wouldn't provide a thirty day notice and we would hold on to them and help them find placement. Usually we find safe placement for them. We evaluate them and give them a planned discharge date . You get priority if you're in the building already. They are priority. But if we don't have a bed we try to help with placement in another facility. We would issue a thirty day notice if we couldn't care for you or meet your needs. We have never not had anyone come back. We have never issued a thirty day notice. They have not been issued a transfer form. We have identified it. There's clearly a communication issue. Based on record reviews, interviews, and review of facility policy, the facility failed to provide written notification of the Bed Hold Policy to Resident Representatives for four (Resident #420, Resident #81, Resident #66, and Resident #114) of five residents sampled for hospitalizations. Findings included: 1. A review of Resident #66's Medical Record revealed that Resident #66 was admitted to the facility on [DATE] with diagnoses of cellulitis of the face and need for assistance with personal care. A review of Resident #66's Progress Notes, dated 10/19/2021 at 04:54 PM, revealed that Resident #66 was sent to the hospital on [DATE] due to a possible stroke. Resident #66's Progress Notes also revealed a note, dated 12/05/2021 at 07:42 AM, which documented that Resident #66 was sent to the hospital on [DATE] due to swelling and redness on the right side of his face. 2. A review of Resident #114's Medical Record revealed that Resident #114 was admitted to the facility on [DATE] with diagnoses of acute appendicitis with perforation, abscess of liver, and sepsis. A review of Resident #114's Progress Notes, dated 12/09/2021 at 12:51, revealed that Resident #114 was sent to the hospital on [DATE] due to poor oral intake and poor participation in therapies. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 6 of 12 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 02/04/2022 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 2/2/2022 at 2:51 PM a request to the facility's Director of Nursing (DON) was made for Resident #66's Bed Hold Policy Notices for the hospital transfers on 10/19/2021 and 12/05/2021, and Resident #114's Bed Hold Policy Notice for the transfer to the hospital on [DATE]. On 2/3/2022 at 8:35 a.m., the DON stated that the Bed Hold Policy Notices were not being completed as required and confirmed they were not completed for Resident #66 or Resident #114 upon transfer to the hospital. The DON reported that nursing staff should be sending the Bed Hold Policy Notices with the resident upon transfer to the hospital, and the resident's representative should be notified. A review of the facility policy titled Bed Hold/readmission Policy, revised in November 2016, revealed under the section titled Procedure that the facility will notify the resident and resident representative at the time of admission and again during an event of hospital transfer or therapeutic leave of its bed-hold and return policies. The notice of bed hold policy will comply with State and Federal rules and laws. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 7 of 12 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 02/04/2022 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to provide ongoing assessment of an intravenous (IV) catheter site for one (Resident #216) of six residents in the facility receiving IV therapy. Residents Affected - Few Findings included: A review of Resident #216's Medical Record revealed that Resident #216 was admitted to the facility on [DATE] with diagnoses of Urinary Tract Infection (UTI) and dehydration. A review of Resident #216's Physician's Orders revealed the following orders: - An order, dated 01/27/2022, to change catheter site dressing with transparent dressing every seven days for IV therapy. - An order, dated 01/31/2022, to observe IV site every shift. A review of Resident #216's Progress Notes, dated 01/29/2022 at 03:26 PM, revealed that Resident #216 had a midline IV catheter inserted to the left upper arm. An observation was conducted on 02/02/2022 at 11:35 AM of Resident #216's midline IV site. Resident #216's left upper arm IV site was observed to be covered by a large gauze pad and wrapped in a self adherent wrap. Resident #216's midline IV site was not able to be fully visualized. An observation was conducted on 02/03/2022 at 09:54 AM during medication administration with Staff B, Licensed Practical Nurse (LPN). Staff B, LPN was observed visualizing the skin around Resident #216's midline IV site, which was covered by a large gauze pad and wrapped in a self adherent wrap. Resident #216's midline IV site did not have a transparent dressing as ordered. An interview was conducted with Staff B, LPN following the observation. Staff B, LPN stated that he was observing Resident #216's IV site for any signs of infection and addressed that Resident #216 did not have a transparent dressing over the IV site. Staff B, LPN stated that he was not allowed to touch the self adherent dressing to the IV site because only a Registered Nurse (RN) was able to apply a transparent dressing to the IV site. Staff B, LPN also stated that he was not able to visualize the actual IV connection and that Resident #216 should have a translucent dressing over the site, but he performs the assessment the best he can. An interview was conducted on 02/04/2022 at 09:56 AM with the facility's Director of Nursing (DON). The DON stated that nursing staff should be assessing IV sites for any redness, warmth, drainage, or any other signs and symptoms of infection. Nursing staff should also assess the IV site to ensure that the transparent dressing does not need changed. The DON stated that a resident with an IV site would need to have a transparent dressing so that the IV site could be properly visualized and assessed. The DON also stated that she would expect the nursing staff to notify her right away if a resident did not have a dressing to their IV site. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 8 of 12 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 02/04/2022 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and review of facility policy, the facility failed to ensure pre and post dialysis assessments were completed for one (Resident #77) of three residents receiving dialysis services in the facility. Residents Affected - Few Findings included: A review of the facility policy titled Dialysis, revised in April 2021, revealed under the section titled Purpose that residents receiving hemodialysis would receive appropriate monitoring and care from the facility and the dialysis provider in order to coordinate care. The policy also revealed, under the section titled pre and post dialysis that a pre-dialysis assessment would be completed before dialysis and a post dialysis form would be completed after dialysis and compared to the pre-assessment. A review of Resident #77's Medical Record revealed that Resident #77 was admitted to the facility on [DATE] with diagnoses of End Stage Renal Disease (ESRD) and dependence on renal dialysis. A review of Resident #77's Physician's Orders revealed an order, dated 02/02/2022, for Pre and Post dialysis notes due Monday, Wednesday, and Friday for dialysis. A review of Resident #77's Pre and Post dialysis notes from 12/31/2021 to 01/31/2022 revealed the following documentation: - No pre or post dialysis assessment was documented on 12/31/2021, 01/03/2022, 01/05/2022, 01/07/2022, 01/10/2022, 01/12/2022, 01/14/2022. 01/17/2022, 01/19/2022, or 01/24/2022. - 01/31/2022: Post dialysis assessment was completed. No pre dialysis assessment was documented. An interview was conducted on 02/02/2022 at 04:39 PM with the facility's Director of Nursing (DON). The DON stated that the facility policy was to use the Dialysis Communication Form to communicate to the resident's dialysis center, but the facility was not using the form. Nursing staff were documenting the pre and post dialysis assessments in the electronic medical record before and after each dialysis appointment. The DON stated that the facility should be using the Dialysis Communication Form and that a dialysis communication log for Resident #77 was not able to be found. A follow up interview was conducted on 02/03/2022 at 08:35 AM with the DON. The DON stated that the dialysis communication book for Resident #77 was still not able to be found and stated that she would create a new one so that communication with the dialysis center could be shared. The DON also stated that the facility was sending the pre dialysis assessment with Resident #77 to dialysis appointments, but there was not a way for the dialysis center to send communication back to the facility on the form. The DON stated that facility staff should be sending the residents face sheet, medication record, and communication form to each dialysis appointment. An interview was conducted on 02/03/2022 at 11:37 AM with Staff A, Licensed Practical Nurse (LPN). Staff A, LPN stated that she had received Resident #77 from his dialysis appointments on a few occasions and that they would normally complete the post dialysis assessment in the electronic medical record following the appointment. Staff A, LPN also stated that residents would normally have a book (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 9 of 12 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 02/04/2022 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 0698 that is sent with them on dialysis appointments to communicate with the dialysis center. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 10 of 12 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 02/04/2022 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews, the facility did not ensure that the pharmacy recommendations were acted upon in a timely manner for one (Resident #98) of five residents sampled for unnecessary medications. Findings Included: A review of Resident #98's admission Record revealed that Resident #98 was admitted to the facility on [DATE] with diagnoses to include Type 2 diabetes, essential (primary) hypertension (HTN), and chronic kidney disease (stage 4). A review of Resident #98's Pharmacy Consultation Report revealed a recommendation, dated 11/15/2021. The recommendation documented that Resident #98 has diabetes, HTN, and/or a decline in renal function. Recommendation: Please initiate Lisinopril 2.5 milligrams (mg) daily, titrating the dose as indicated. This recommendation was accepted by the physician; however, a 2nd Pharmacy Consultation Report dated 01/10/2022 stated Resident #98's prescriber accepted a pharmacy recommendation to initiate Lisinopril, but the order has not yet been processed (see signed pharmacy recommendation from 11/15/21 in electronic medical record system). Please process the accepted pharmacy recommendation and update the medical record accordingly. A review of Resident #98's Medication Records, dated 11/15/2021 to 2/3/2022 revealed that Lisinopril Tablet 2.5 mg was not administered to Resident #98. An interview was conducted on 02/03/2022 at 02:40 PM with the facility's Director of Nursing (DON), with the Consultant Pharmacist (CP) on the phone. The DON stated the order pharmacy recommendation accepted but not processed; Process, dated 01/10/2022, is a reference to the pharmacy recommendation on 11/15/2021. The recommendation was please initiate Lisinopril 2.5 mg, titrating the dose as indicated. The DON stated a nurse noted on the bottom of the 11/15/2021 recommendation sheet no Lisinopril ordered at this time 12/02/2021. The DON stated that it was a possibility that the note was written by the nurse prior to the doctor signing the recommendation but was not able to confirm. The DON stated she followed up on 02/03/2022 with the physician, and the physician stated to go ahead and start the prescription today, 02/03/2022. Both the DON and CP stated that there was a miscommunication, and that Resident #98 has not received Lisinopril 2.5 mg. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 11 of 12 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 02/04/2022 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, record review, and interview, the facility failed to store food in accordance with professional standards for food service safety related to ensuring foods in the walk-in cooler and dry storage room were labeled, dated, and discarded by the use by date. Findings included: On 02/01/22 at 10:40 a.m., an initial tour of the kitchen was conducted with the Certified Dietary Manager (CDM) and the Registered Dietitian (RD). The following was observed in the walk-in cooler: an opened bag of shredded cheese undated; a carton of milk with a use by date of 01/24/22; two red and white containers of specialty salads with carrot raisin written on the container with a use by date of 01/13/22; two red and white containers of specialty salads with carrot raisin written on the container with a use by date of 01/27/22; five red and white containers of coleslaw with a use by date of 01/28/22; one red and white container of specialty salad with a use by date of 01/31/22; and an opened container of Deli Tuna undated (photographic evidence obtained). The following was observed in the dry storage room: an opened package of seasoning wrapped in plastic undated, and an opened package of biscuits wrapped in plastic wrap without a date. On 02/03/22 at 11:00 a.m., the CDM reported everyone was responsible for ensuring foods were dated, labeled, and not expired. She stated her expectations was that all foods were dated, labeled, and no expired foods in the kitchen. The policy provided by the facility Digital Food Labeling with an original date of 03/2020 revealed the following: 1. All leftover foods and opened packages must be properly labeled to comply with food safety standards. On 02/04/22 at 11:30 a.m., a policy related to expired foods was requested and not provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 12 of 12