Inspection·March 26, 2024

F 0644 Level of Harm - Minimal harm or potential for actual harm Policy: The Level I and II process is designed to determine the most appropriate setting for persons with a mental illness and/or intellectual or developmental disabilities and to identify the rehabilitation or specialized services that the person requires. It is the policy of this facility to participate in the Level I/Level II process. Procedure: Residents Affected - Some 1. A Level I screen will be completed for all resident's [sic] admitted to the facility. If a level II is indicated at the time of admission, the Level II also will be completed prior to the resident being admitted to the facility. 2. Social Service Director or appointed designee will review all Level I's upon admission and a minimum of annually thereafter . 5. Social Service Director or designee will refer residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition to the state mental health authority or the state intellectual authority. Documentation will be made in the progress notes. 3. On 3/23/24 at 2:09 p.m. Resident #70 was observed lying in bed, a piece of white gauze with a nickel-sized reddish-brown colored stain was attached to the inner portion of the resident's right arm. The resident stated, They told me not to remove it. Review of a progress note, 3/22/24 at 3:10 p.m., revealed the resident had pulled Intravenous (IV) line out and gauze had been applied. Review of Resident #70's admission Record revealed the resident had been admitted on [DATE] and included diagnoses of cognitive communication deficit, unspecified severity unspecified dementia without behavioral, psychotic and mood disturbances and anxiety. Review of Resident #70's PASARR Level I, completed at an acute care facility on 11/22/23, showed the resident had no Mental Illness (MI), Suspected MI (SMI), Intellectual Disability (ID) or Suspected ID (SID) based on documented history and medications. The evaluation did reveal the resident had positive findings of serious interpersonal functioning and serious difficulty in sustaining concentration, persistence, and pace related to the completion of tasks. The PASARR revealed the resident had no diagnosis or suspicion of a SMI or ID therefore a Level II evaluation was not required. Review of Resident #70's active physician orders revealed the following: - Psychological/Psychiatric evaluation and treatment. Started 11/22/23. - Depakote 125 milligram (mg) Delayed Release - Give 1 tablet every 12 hours for mood stabilization, started 3/15/24. - Sertraline 50 mg - Give 1 tablet by mouth at bedtime for depression, started 11/22/23. Review of Resident #70's Psychological Diagnostic Evaluation, dated 12/1/23, showed the primary psychological diagnosis was Adjustment disorder with mixed anxiety and depressed mood. The evaluation revealed the resident had been referred to psychology due to having a diagnosis of depression, current psych meds (medications) were Sertraline (and) Depakote, and a current/past psychiatric diagnoses included Dementia and Depression. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 2 of 31 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 03/26/2024 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #70's Behavioral Health Note, dated 1/30/24, revealed the resident had a diagnosis of depression and was currently taken Zoloft, denied sadness/depression that day however energy had decreased. The narrative revealed the resident Occasional irritability/resistance to redirection, however no combative/aggressive behavior. The note revealed the resident was receiving the medication Zoloft for depression and Depakote for dementia with behaviors, a Gradual Dose Reduction (GDR) had been considered but contraindicated. The visit note revealed the Primary Psychiatric diagnosis for the resident was Adjustment disorder with anxiety and the secondary diagnosis was Mild single episode Major depressive disorder. Review of Resident #70's Quarterly Minimum Data Set (MDS), dated [DATE], showed the resident did not voice any issues with mood, however the resident had delusions, and no behaviors. The assessment did not include the resident's psychiatric diagnosis of adjustment disorder or depression. Based on interview and record review, the facility failed to revise the Level I Pre-admission Screening and Resident Review (PASARR) with a newly identified diagnosis and failed to resubmit for a PASARR Level II review for four residents (#54, #20, #70, and #61) of 37 residents reviewed. Findings included: 1. Review of the admission Record revealed Resident #54 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include unspecified dementia, cognitive communication deficit, and unspecified psychosis not due to a substance or known physiological condition. On 1/29/24 the diagnosis of adjustment disorder with mixed anxiety and depressed mood was added. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed: -Section C - Cognitive Patterns: Brief Interview for Mental Status (BIMS) score 07, indicating severe cognitive impairment. -Section I Active Diagnosis - non-Alzheimer's Dementia, psychotic disorder and adjustment disorder with mixed anxiety and depressed mood. -Section N Medications: administered - antipsychotic, antianxiety and antidepressant. Review of the Medication Administration Record (MAR) for March 2024 showed: - Trazodone HCI Oral Tablet 50 MG (milligram) - Give 1 tablet by mouth at bedtime for Depression, start date 12/7/23, -Quetiapine Fumarate Oral Tablet 50 MG - Give 1 tablet by mouth at bedtime for Mood disorder, start date 12/7/23, -Ativan Oral Tablet .5 MG - Give .5 mg by mouth every 6 hours as needed for anxiety for 30 days, start date 3/13/24. Review of the PASSAR Level I, dated 7/31/23, revealed: -Section IA, no Mental Illness, or suspected Mental Illness checked. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 3 of 31 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 03/26/2024 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 0644 -Section II 5 primary diagnosis of Dementia checked no. Level of Harm - Minimal harm or potential for actual harm -Section II 6 secondary diagnoses of Dementia checked no. Residents Affected - Some On 3/26/24 at 2:43 p.m. during an interview with the Social Services Director, she confirmed the dementia diagnosis was not captured and should have been documented on the PASARR Level I. She stated a PASARR Level I should have been completed with the new diagnoses of psychosis, and adjustment disorder with mixed anxiety and depressed mood. She stated when a Level I is input into the system the algorithm in the system would alert her if a Level II was needed for the resident. 2. Review of the admission MDS, with the target date of 8/7/23, revealed Resident #20 was admitted to the facility on [DATE] with diagnoses to include unspecified dementia. The MDS also showed: -Section C - Cognitive Patterns: Brief Interview for Mental Status (BIMS) score 06, indicating severe cognitive impairment. -Section I - Active Diagnosis - Dementia was checked. -Section N - Medications: administered - no antipsychotics administered. Review of the PASARR Level I, dated 7/27/23, revealed: -Section IA, no Mental Illness, or suspected Mental Illness checked. -Section II 5 primary diagnosis of Dementia checked yes. -Section II 6 secondary diagnoses of Dementia checked no. Review of the medical record showed a diagnosis of major depressive disorder was added as of 11/21/23. Continued review of the medical record revealed the medical record was silent of a new PASARR Level I or a PASARR Level II. On 3/26/24 at 2:40 p.m. the Social Services Director confirmed there was not a revised PASARR Level I or a PASARR Level II for Resident #20. She stated when the diagnosis of depressive disorder was added another Level I screen should have been completed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 4 of 31 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 03/26/2024 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure the accuracy of the Preadmission Screening and Resident Review (PASARR) for two residents (#101, and #77) out of 37 residents sampled. Residents Affected - Few Findings included: 1. On 3/23/24 at 1:48 p.m. Resident #101 was overheard from the hallway yelling out non-sensical words. Staff D, Certified Nursing Assistant (CNA) and Staff E, CNA were observed leaving the resident's room. Staff D stated the yelling was a behavior and asked this writer to shut the door as the screaming out affects other residents. The resident quieted during the observation then began yelling out non-sensical words, which continued after this writer left the room. Review of Resident #101's admission Record showed the resident was admitted on [DATE] and included the diagnoses with an onset date of 9/21/23 of unspecified severity unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, mild recurrent major depressive disorder, and anxiety. The record revealed diagnoses added after the resident's admission were unspecified anxiety disorder (onset date 10/14/23), mild single episode major depressive disorder (onset date 10/22/23), and senile degeneration of brain not elsewhere classified (onset date 11/17/23). Review of Resident #101's PASARR, dated 9/21/23 and completed at an acute care facility revealed the resident had diagnoses of anxiety, depressive, and psychotic disorders. The PASARR showed the resident had a primary diagnosis of dementia and did not have any disorder resulting in functional limitations, did not have a serious difficulty interacting appropriately and communicating effectively with other persons, did not have a serious difficulty in sustaining focused attention, and did not have a serious difficulty adapting to typical changes. The PASARR screen completion revealed the resident did not have a diagnosis or suspicion of a Serious Mental Illness or Intellectual Disability and a Level II evaluation was not required. Review of Resident #101's physician orders revealed the resident was admitted to hospice on 11/18/23 with a terminal diagnosis of senile degeneration of the brain. The following active physician orders showed the resident received psychotropic medications and was being monitored for side effects related to the use of those medications: - Observe for side effects (antipsychotic, antidepressant, antianxiety, (and) hypnotic). Y = yes side effects were noted - see progress notes. N = no side effect noted, every shift. Started on 9/30/23. - Psychological/Psychiatric evaluation and treatment. Started on 9/21/23. - Ativan 1 milligram (mg) - Give one tablet by mouth every 6 hours as needed for agitation/anxiety for 14 days. Started on 3/23/24. - Clonazepam 1 mg - Give 1 tablet by mouth every 6 hours for agitation. Started on 3/26/24. - Clonazepam 1 mg - Give 1 tablet by mouth every 8 hours for agitation. Started 3/8/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 5 of 31 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 03/26/2024 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few - Duloxetine Delayed Release Particles 30 mg - Give 1 capsule by mouth two times a day for depression. Started 9/22/23. - Melatonin 3 mg tablet - Give 1 tablet by mouth at bedtime for sleep. Started 11/28/23. - Mirtazapine 15 mg - Give 0.5 tablet by mouth at bedtime for depression, poor oral (po) intake. Started on 11/28/23. - Seroquel 50 mg - Give 1 tablet by mouth two time a day. Started 3/26/24. Review of Resident #101's care plan revealed the following focuses and interventions: - I am currently prescribed an antidepressant medication, initiated 9/22/23. The interventions included staff would reevaluate my medication with any significant change in condition/status, initiated on 9/22/23. - I am currently prescribed an antianxiety medication, initiated 9/22/23. The interventions included the resident would receive the medication as prescribed. - I am at risk for adverse side effects related to my use of an antidepressant and antianxiety medication, initiated 9/22/23. - I have behavioral symptoms such as choosing not to have care provided or participate in Activities of Daily Living (ADL's), having my incontinent undergarments changed, eat my meals, allow staff to weigh or shower me secondary to my cognitive deficit and terminal diagnosis of Senile Degeneration of the Brain, initiated 10/5/23. Review of Resident #101's Quarterly Minimum Data Set (MDS) dated [DATE], revealed Active Diagnosis included diagnoses not limited to non-Alzheimer's dementia, anxiety and depression disorders, and Senile degeneration of brain not elsewhere classified. Review of Section E - Behavior, revealed the resident had delusions as potential indicators of psychosis and no other behaviors. 2. A review of Resident #77's admission Record revealed Resident #77 was originally admitted to the facility on [DATE]. Further review showed Resident #77 had diagnoses to include unspecified dementia, anxiety disorder, and cognitive communication deficit. A review of Resident #77's Level I PASARR assessment, dated 10/13/21, revealed, under the section titled A. MI (Mental Illness) or suspected MI (check all that apply), the checkbox for the selection Anxiety Disorder, was checked. Review of Section II Other Indications for PASRR [sic] Screen Decision- Making showed: 5. Does the individual have a primary diagnosis of: dementia? Checked as No; and Related Neurocognitive Disorder (including Alzheimer's disease)? Checked as No. 6. Does the individual have a secondary diagnosis of dementia, related neurocognitive disorder (including Alzheimer's disease) and the primary diagnosis is an [sic] Serious Mental Illness or Intellectual Disability? Checked as Yes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 6 of 31 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 03/26/2024 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 7. Does the Individual have validating documentation to support dementia or related neurocognitive disorder (including Alzheimer's disease)? Checked as Yes - documented history. A review of Resident #77's Minimum Data Set (MDS) assessment, dated 1/26/24, revealed, under Section C: Cognitive Patterns no score for the Brief Interview for Mental Status (BIMS). This section showed the resident is rarely/never understood. Section I: Active Diagnoses documented Resident #77 had non-Alzheimer's Dementia, and anxiety disorder. Further record review of the medical record for Resident #77 revealed no evidence a Level II PASARR was completed. During an interview on 3/26/24 at 2:36 p.m. the Social Services Director reviewed the PASARR Level I Screen for Resident #77 and confirmed anxiety was checked for a MI/Suspected MI, and dementia was check as a secondary diagnosis. She confirmed a Level II was not submitted. Review of the instructions on the PASARR Level I form showed: A Level II PASRR [sic] evaluation must be completed if the individual has a primary or secondary diagnosis of dementia or related neurocognitive disorder, and a suspicion or diagnosis of an Serious Mental Illness, Intellectual Disability, or both. A Level II PASRR [sic] may only be terminated by the Level II PASRR [sic] evaluator . Review of a policy titled: Level I and Level II Process, revised 4/22, revealed: Policy: The Level I and II process is designed to determine the most appropriate setting for persons with a mental illness and/or intellectual or developmental disabilities and to identify the rehabilitation or specialized services that the person requires. It is the policy of this facility to participate in the Level I/Level II process. Procedure: 1. A Level I screen will be completed for all resident's [sic] admitted to the facility. If a level II is indicated at the time of admission, the Level II also will be completed prior to the resident being admitted to the facility. 2. Social Service Director or appointed designee will review all Level I's upon admission and a minimum of annually thereafter . 5. Social Service Director or designee will refer residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition to the state mental health authority or the state intellectual authority. Documentation will be made in the progress notes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 7 of 31 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 03/26/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to develop comprehensive care plans for three residents (#71, #75 and #77) related to advanced directives out of forty four residents sampled, and one resident (#59) related to identifying the target behaviors exhibited out of five residents sampled for unnecessary medications. Findings included: 1. Review of Resident #71's admission Record revealed an admission date of 3/29/22 and that she was a hospice patient. Resident #71's medical diagnoses included encephalopathy, multiple myeloma in remission, and anxiety disorder. The admission Record showed Resident #71's Advance Directive was Do Not Resuscitate (DNR). Review of Resident #71's current comprehensive care plan, revised as of 12/2023, was silent of a Focus, goal or interventions related to Advance Directives. On 3/26/24 during an interview that started at 6:17 p.m., Staff J, Minimum Data Set Coordinator/Licensed Practical Nurse (MDS/LPN) stated we (facility) should have an Advance Directives care plan for each resident. She reviewed the care plan for Resident #71 and stated, Nope, I don't see one for [Resident #71]. 2. Review of Resident #75's admission Record revealed an admission date of 2/22/24 and that she was a hospice patient. Resident #75's medical diagnoses included chronic obstructive pulmonary disease, and unspecified dementia. The admission Record showed Resident #75's Advance Directive was Do Not Resuscitate (DNR). Review of Resident #75's current comprehensive care plan, initiated on 2/23/24, was silent of a Focus, goal or interventions related to Advance Directives. On 3/26/24 during an interview that started at 6:17 p.m., Staff J, MDS/LPN reviewed the care plan for Resident #75 and confirmed Resident #75 did not have a care plan for Advance Directives. 3. Review of Resident #77's admission Record revealed the most recent admission date of 2/10/22 and that she was a hospice patient. Resident #77's medical diagnoses included respiratory failure and unspecified dementia. The admission Record showed Resident #77's Advance Directive was Do Not Resuscitate (DNR). Review of Resident #77's current comprehensive care plan, recently revised as of 3/23/24, was silent of a Focus, goal or interventions related to Advance Directives. On 3/26/24 during an interview that started at 6:17 p.m., Staff J, MDS/LPN reviewed the care plan for Resident #77 and stated, I don't see one for [Resident #77]. 4. On 3/24/24 at 9:41 a.m., Resident #59 was observed lying in bed with some confusion. On 3/24/24 at 11:45 a.m. Resident #59 was observed sitting in a wheelchair between the two beds (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 8 of 31 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 03/26/2024 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 0656 occupying the room. Level of Harm - Minimal harm or potential for actual harm Review of Resident #59's admission Record showed the resident was admitted on [DATE] and included diagnoses of adjustment disorder with mixed anxiety and depressed mood, unspecified anxiety disorder, and mild recurrent major depressive disorder. Residents Affected - Some Review of Resident #59's care plan revealed the following: - I am currently prescribed an antianxiety medication. The interventions included: You will adequately monitor my dose, duration, and indication of use. - I am currently prescribed an antidepressant. The interventions included: You will adequately monitor my dose, duration, and indication of use. - I am currently prescribed an antipsychotic medication. The interventions included: You will adequately monitor my dose, duration, and indication of use. - I have behavioral symptoms such as choosing not to have care provided, refuse to allow staff to get me out of bed at times, refuse to allow staff to shower me, (and) sign and symptoms of psychosis. The interventions included: I will report and you will observe for changes in my behaviors, determine if any alterations in care plan is needed. - I have depression as evidenced by change in living environment, chronic pain, (and) progression of disease process. The interventions included I will report and you will observe for changes in my depression symptoms. - I have a diagnosis of depression and present with signs/symptoms of depression such as lack of energy, feelings of sadness, behavioral changes of hallucinations and delusions at times. The interventions included, I will receive my medications as ordered. This focus was added on 3/24/24. Review of Resident #59's care plan did not reveal target behaviors exhibited by the resident that staff was instructed to be observing for necessitating the use of antianxiety and antipsychotic medications. Review of Resident #59's active Order Summary Report revealed the following: - Buspirone 5 milligram (mg) - Give 1 tablet by mouth two times a day for anxiety, started on 3/15/24. - Cymbalta Delayed Release particles 30 mg - Give 1 capsule by mouth in the evening for depression, started 5/2/23. - Duloxetine Delayed Release particles 60 mg - Give 1 capsule by mouth one time a day for depression, started 3/22/23. - Mirtazapine 7.5 mg - Give 1 tablet by mouth at bedtime for depression, poor po (oral) intake, started 8/3/23. - Seroquel 25 mg - Give 0.5 tablet by mouth two times a day for psychosis, started 3/25/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 9 of 31 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 03/26/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Review of Resident #59's Behavioral Health Note, dated 3/15/24, revealed the resident was discussed in psych med (medication) meeting for a consideration of a Gradual Dose Reduction (GDR). The note revealed since the last visit the resident hasn't had any further agitation/aggression/paranoia and staff had reported the resident was getting out of bed and attending activities. The note showed the decision was made to reduce Buspar (Buspirone) to 5 mg twice daily and reassess in two weeks. Residents Affected - Some Review of Resident #59's Behavioral Health Note, 3/25/24, history of present illness revealed since admission the resident exhibited periods of irritability/anxiety/frustration related to (r/t) medical issues, decline in functional ability, and placement. The note showed the resident had exhibited frequent episodes of irritability and periods of anxiety with Cymbalta being increased, in August the resident had increased confusion, visual hallucinations (VH), periods of anxiety and agitation. A GDR of Buspar occurred on 3/15/24 and since the weekend has been noted with increased confusion, periods of agitation and fluctuating delusions. The resident was with VH (snakes in room) and paranoid delusions that are causing distress. An interview was conducted with Staff J, MDS/LPN on 3/26/24 at 6:03 p.m. Staff J stated residents' care plans should include watching out for adverse reactions, GDR/psych services as needed, monitor for side effects, monitor of increased behaviors, and will increase risk for falls. Staff J stated for a behavior the facility would do a separate care plan (related to use of psychotropic medications), example given was aggression would be on separate care plan not necessarily the medication one. A review of Resident #59's care plan was done with Staff J. Staff J reviewed the focus related to the use of antidepressant and antipsychotic medications which instructed to monitor for signs and symptoms of psychosis. Staff J stated the care plan should identify the type of psychosis the resident exhibited and confirmed there was no focus related to how the resident exhibited antianxiety behaviors. During an interview on 3/26/24 at 4:53 p.m. the Director of Nursing reported Resident #59 typically hallucinates (about) snakes and frogs. The DON stated the resident will also report someone took blood from top of hand and inserted a microphone, which she demonstrated the resident would speak into. Review of the policy titled, Care Planning, revised 10/22, showed, It is the policy of this facility to develop a comprehensive plan of care that is individualized and reflective of the resident's goals, preferences, and services that are to be provided to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being. According to the policy, Person-Centered Care was defined has a focus on the resident as focus of control and support the resident in making their own choices and having control over their daily lives. Review of the policy titled, Psychoactive Medications/Gradual Dose Reduction (GDR)/Unnecessary Medications Policy, revised 4/23, revealed, It is the policy of this facility that a resident will receive medications and psychoactive medications only when it is necessary to improve the resident's overall psychosocial health status. The policy showed Residents receiving psychoactive medications will have a care plan initiated that contains resident diagnosis and interventions regarding the target behaviors and possible adverse side effects of the medication(s). The risks/benefits will be explained to resident/resident representative and consent or denial obtained for use of required medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 10 of 31 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 03/26/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure physician ordered medications were available for two residents (#63 and #35) of forty four sampled residents. Findings included: 1. A review of Resident #63's admission Record revealed Resident #63 was admitted to the facility on [DATE] with diagnoses of monoplegia of lower limb affecting the left side, postpolio syndrome, and muscle weakness. A review of Resident #63's physician's orders revealed the following orders: - An order, dated 3/21/2024 for diclofenac sodium 1% gel apply topically to both knees every 8 hours as needed for pain. - An order, dated 1/8/2024 for testosterone cypionate injection 200 milligrams (mg)/milliliter (ml), inject one application intramuscularly (IM) one time every 2 weeks on Monday for low testosterone. An interview was conducted on 3/23/2024 at 10:40 a.m. with Resident #63 in the resident's room. Resident #63 stated he recently had pain relief cream (diclofenac sodium 1% gel) ordered for knee pain, but had not yet received the cream because the facility had not received the cream from the pharmacy. Resident #63 stated he received testosterone injections every 2 weeks, but he was not getting them as often as he should be getting them. A review of Resident #63's Medication Administration Record (MAR) for January 2024 revealed Resident #63 did not receive the ordered testosterone cypionate injection on 1/22/2024. The entry in the MAR on that date was documented as 9=Other / See Progress Notes. A review of Resident #63's MAR for February 2024 revealed Resident #63 did not receive the ordered testosterone cypionate injection on 2/5/2024 or 2/19/2024. The entries in the MAR on those dates was documented as 9=Other / See Progress Notes. A review of Resident #63's MAR for March 2024 revealed Resident #63 did not receive the ordered testosterone cypionate injection on 3/18/2024. The entry in the MAR on that date was documented as 9=Other / See Progress Notes. Resident #63's MAR for March 2024 also revealed Resident #63 did not receive any applications of diclofenac sodium 1% gel since it was ordered on 3/21/2024. A review of Resident #63's Progress Notes revealed the following MAR notes related to Resident #63's testosterone cypionate injection not being administered: - A note dated 1/22/2024 at 9:29 AM: Awaiting pharmacy. The note did not reveal notification of Resident #63's physician or an attempt to contact the pharmacy. - A note dated 2/5/2024 at 10:35 AM: Spoke to pharmacy, pharmacy stated being a high cost med (medication). Fax will be sent with form. Medication not in [emergency drug kit], MD (medical doctor) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 11 of 31 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 03/26/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm aware. Resident #63's progress notes did not reveal any follow up documentation related to the administration or receipt of the medication. - A note dated 2/19/2024 at 8:19 AM: On order. The note did not reveal notification of Resident #63's physician or an attempt to contact the pharmacy. Residents Affected - Few - A note dated 3/18/2024 at 10:49 AM: Spoke to pharmacy, new script (prescription) is needed. MD aware. Unit manager aware. Awaiting for medication. Resident #63's progress notes did not reveal any follow up documentation related to the administration or receipt of the medication. Review of Resident #63's progress notes did not reveal any follow up with the pharmacy regarding Resident #63's diclofenac sodium 1% gel. A follow up interview was conducted on 3/25/2024 at 9:44 a.m. with Resident #63 in the resident's room. Resident #63 stated he had not received his cream (diclofenac sodium 1% gel) for his knees and the nursing staff told him the cream was still not received from the pharmacy. During the interview, Resident #35, who was Resident #63's roommate, stated he did not receive his ordered cream for his knees either. Resident #35 stated he had an order for the same cream as Resident #63. 2. A review of Resident #35's admission Record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses of pneumonia, muscle wasting and atrophy, and muscle weakness. A review of Resident #35's physician's orders revealed an order, dated 3/18/2024 for diclofenac sodium 1% gel apply topically to both knees every 12 hours as needed for pain. Review of Resident #35's progress notes did not reveal any follow up with the pharmacy regarding Resident #35's diclofenac sodium 1% gel. An interview was conducted on 3/25/2024 at 9:56 am. with Staff C, Licensed Practical Nurse (LPN), who was Resident #63's and Resident #35's assigned nurse for the 7:00 a.m. to 3:00 p.m. shift. Staff C, LPN stated Resident #63's diclofenac sodium 1% gel was ordered from the resident's physician on Wednesday (3/20/2024) and the medication was still on order from the pharmacy when she was working on Friday 3/22/2024. Staff C, LPN reviewed Resident #63's medications and diclofenac sodium 1% gel was shown in the electronic MAR as on order. Staff C, LPN stated she was not sure if any other nursing staff followed up with the pharmacy regarding the whereabouts of the medication and stated nursing staff would usually follow up with the pharmacy if a medication had not arrived. Staff C, LPN opened the treatment cart on the 600 unit and attempted to find diclofenac sodium 1% gel for Resident #63 or Resident #35. Staff C, LPN was not able to locate the diclofenac sodium 1% gel for either resident in the treatment cart. Staff C, LPN opened the treatment cart on the 400 unit and attempted to find diclofenac sodium 1% gel for Resident #63 or Resident #35. Staff C, LPN was not able to locate the diclofenac sodium 1% gel for either resident in the treatment cart. A follow up interview was conducted on 3/26/2024 at 10:46 a.m. with Staff C, LPN. Staff C, LPN stated Resident #63 received testosterone injections every two weeks and had lab work performed every two weeks to assess the resident's testosterone levels. The results of the lab work are sent to Resident #63's physician to determine if the testosterone therapy is still needed. Staff C, LPN reviewed Resident #63's MAR and stated she was at the facility on 3/18/2024 and Resident #63's testosterone cypionate injection was not available and was on order from the pharmacy. Staff C, LPN reviewed Resident #63's progress notes and was not able to find notes for follow up with the pharmacy related to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 12 of 31 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 03/26/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #63's testosterone cypionate injections. Staff C, LPN stated if the order for the testosterone cypionate injection was current then the resident should be getting it. An interview was conducted on 3/26/2024 at 5:08 p.m. with the facility's Director of Nursing (DON). The DON stated when a new medication is ordered for a resident, the order is electronically sent to the pharmacy and the medication should be delivered on the next pharmacy run. The DON also stated pharmacy runs are completed three times a day on Monday through Friday and twice a day on Saturday and Sunday. The DON stated if a medication does not arrive from the pharmacy, the nurse should follow up with the pharmacy and document the follow up in the resident's progress notes. If a medication is not administered, the resident's physician should be notified. The DON stated the nurse should have called the pharmacy regarding Resident #63's testosterone cypionate injection so a new prescription could be obtained from the resident's physician. The DON also stated it would not typically take very long to get a medication from the pharmacy, especially considering the diclofenac sodium 1% gel is an over-the-counter (OTC) medication and it could be obtained from a nearby store. The DON would expect nursing staff to notify a unit manager, a supervisor, or herself to obtain an OTC medication so it could be purchased immediately. A review of the facility policy titled, Pharmacy Services, last revised in February 2020, revealed under the section titled Policy it is the policy of the facility to provide routine and emergency drugs to residents according to the physician's orders. The policy also revealed under the section titled Procedure the facility will provide pharmacy services including accurate acquiring of medications, receiving of medications, dispensing of medications, and administering of medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 13 of 31 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 03/26/2024 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to prevent the administration of a medication listed as an allergy and failed to notify the physician of the administration the medication for one resident (#55) of seven sampled residents,. Residents Affected - Few Findings included: A review of the admission Record revealed Resident #55 was admitted to the facility on [DATE] with diagnoses to included metabolic encephalopathy, generalized anxiety, pressure ulcer of sacral region, stage 4 and heart failure. Review of the Minimum Data Set assessment, dated 2/2/24, revealed in Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 14, indicating cognitively intact. Section N - Medications showed opioids were administered. Review of the electronic medical record showed the allergies listed for Resident #55 as Morphine, Lasix, Lyrica and shellfish. Review of the Order Summary Report for 3/1/24 - 3/31/24 showed the allergies listed as Morphine, Lasix, Lyrica and shellfish. Review of the Medication Administration Record (MAR) for February 2024 showed the allergies listed as Morphine, Lasix, Lyrica and shellfish. Further review showed the physician orders as: -Morphine sulfate (Concentrate) Oral Solution 20 MG/ML (milligrams/milliliters) - give 0.5 ml by mouth every 2 hours as needed for pain, start date 1/29/24 17:30 ; no end date (not administered in February), Review of the March 2024 MAR showed the allergies listed as Morphine, Lasix, Lyrica and shellfish. Further review showed active physician orders as: -Morphine sulfate (Concentrate) Oral Solution 20 MG/ML (Morphine Sulfate) - give 0.5 ml by mouth every 2 hours as needed for pain, start date 1/29/24 17:30 (5:30 p.m.); no end date. The MAR showed the administration of the medication on 3/6/24 for a pain level of 6 and on 3/21 for a pain level of 5 with both administrations being effective. Review of the electronic medical record progress note, dated 3/21/24 at 23:45 (11:45 p.m.) showed the administration of Morphine Sulfate (concentrate). A review of Resident #55's care plan, initiated on 1/30/24, revealed a Focus as I am currently prescribed an opioid medication. The Goal was noted as I will have no adverse side effects from my medication. Interventions included: you will revaluate my medication with any significant change in condition/status, you will routinely evaluate if this medication can be reduced or discontinued. Review of the electronic medical record revealed the date of 3/14/24 as the date the allergy to Morphine was added. Review of the daily skilled notes for 3/13/24 and 3/14/24 were silent to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 14 of 31 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 03/26/2024 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 0757 documentation related to the allergy to morphine. Level of Harm - Minimal harm or potential for actual harm Review of the medical record to include physician notes dated 3/13/24, 3/18/24 and 3/20/24 did not reveal documentation related to a Morphine allergy. Residents Affected - Few Review of the Wound Evaluation and Management Summary report, dated 3/18/24, showed Lasix and Lyrica as allergies. During an interview with Resident #55 on 3/25/24 at 1:38 p.m., she stated she was allergic to Lasix and Lyrica. She said she was not allergic to Morphine her [family member] must have told the facility that. She said, I'm not. I've had it since I've been here .I take it every once in while when my butt hurts. During an interview with Staff P, Licensed Practical Nurse (LPN) on 3/25/24 at 2:40 p.m., she stated Resident #55 can make her needs known when she is in pain. She does have Morphine if it reaches that stage in level of pain. She reviewed the electronic medical record and confirmed the physician order for Morphine was active. During an interview with the Director of Nursing (DON) on 3/26/24 at 4:47 p.m., she reviewed the March 2024 MAR and confirmed the administration of Morphine to Resident #55 on 3/21/24 at 23:45 and 3/26 at 4:16 a.m. She confirmed Morphine was listed as an allergy for this resident and stated it is a mild intolerance. She said it probably should have been taken off. She clarified if the nursing staff see the allergy popping up on the screen they should notify the doctor. She reviewed the record and stated, I do not see they notified the doctor. She stated if the nurses are getting a warning of a potential issue they should notify the physician. She stated it (Morphine) should never have been listed as that (allergy). She stated they should get an order to d/c (discharge it). Review of the policy titled, Medication Administration, implemented 3/14/24, revealed the Policy as: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: 10. Ensure that the six rights of medication administration are followed: a. Right resident b. Right drug c. Right dosage d. Right route e. Right time f. Right documentation 21. Correct any discrepancies and report to nurse manager. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 15 of 31 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 03/26/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to monitor the behaviors of two residents (#59 and #55) out of five residents sampled for the use of psychotropic medications. Findings included: 1. On 3/24/24 at 9:41 a.m. Resident #59 was observed lying in bed complaining of seeing a physician in six weeks and had not been out of bed for nine weekends. Review of Resident #59's admission Record revealed the resident was admitted on [DATE] and included diagnoses of adjustment disorder with mixed anxiety and depressed mood, unspecified anxiety disorder, and mild recurrent major depressive disorder. Review of Resident #59's Order Summary Report, which included active physician orders, showed the resident was ordered the following: - Observed for side effects (antipsychotic, antidepressant, antianxiety, (and) hypnotic), Y=yes side effects were noted - see progress notes. N= No side effects noted, every shift for see above. - Buspirone 5 milligram (mg) - Give 1 tablet by mouth two times a day for anxiety. Started on 3/15/24. - Cymbalta Delayed Release Particles (Duloxetine) 30 mg - Give 1 capsule by mouth in the evening for depression. Started 5/2/23. - Duloxetine Delayed Release Particles 60 mg - Give 1 capsule by mouth one time a day for depression. Started 3/21/23. - Mirtazapine 7.5 mg - Give 0.5 tablet by mouth at bedtime for depression, poor oral (po) intake. Started 8/3/23. -Seroquel 25 mg - Give 0.5 tablet by mouth two times a day for psychosis for 7 days. Started 3/25/24, end 4/1/24. Review of Resident #59's Order Summary Report did not show an order instructing staff to monitor for the behaviors related to the use of the resident's prescribed psychotropic medications. Review of Resident #59's Behavioral Health Note, written by an outside vendor, dated 3/15/24, showed the resident was discussed in psych med (medication) meeting with Interdisciplinary team (IDT) for consideration of a Gradual Dose Reduction (GDR). The note revealed since the last visit, resident had not had any further agitation/aggression/paranoia. The resident had no new behavioral concerns, changes in mood or anxiety/restlessness noted per staff. The note showed a GDR attempt was made by reducing the resident's Buspar (Buspirone) to 5 mg twice daily (BID). Review of Resident #59's Behavioral Health note, written by an outside vendor, dated 3/25/24, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 16 of 31 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 03/26/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few showed Since admission, periods of irritability/anxiety/frustration related to (r/t) medical issues, decline in functional ability, and placement. The resident reported to the Nurse Practitioner (NP) current medications helped with anxiety and anger and presented as quite irritable during visit and unable to fully engage. The staff reported frequent irritability with periods of anxiety and Cymbalta was increased during the last visit. Resident was having some increased anxiety/yelling out/increased confusion/visual hallucinations (VH), (and) periods of anxiety and agitation. The nurse reported was tired and having low energy; mood, anxiety, confusion, and VH were improved. recently had an episode of agitation/aggression/paranoia per staff. A GDR of Buspar on 3/15/24 and was tolerating well, however since the weekend (resident) noted with increased confusion, periods of agitation, and fluctuating delusions. Resident with VH (snakes in (resident) room) and paranoid delusions that are causing distress. The plan and recommendation instructed staff to monitor for sleep, appetite, mood, (and) anxiety. Review of a note written by Resident #59's primary care physician, on 3/24/24, revealed the resident's cognition was off, impaired concentration, seemed to be more anxious, and had flights of ideas jumping from subject to subject. Review of Resident #59's Minimum Data Set (MDS) , dated 3/2/24, revealed the resident had no mood symptoms such as little interest or pleasure in doing things or feeling down, depressed, or hopelessness in the two weeks prior to the evaluation and had no indicator of psychosis or any physical, verbal or other behavioral symptoms, or rejection of care prior to the evaluation period. Review of Resident #59's care plan revealed the following Focuses and related interventions: - I am currently prescribed an antianxiety medication, initiated 3/1/23 and revised 3/14/24. The related interventions included instructions to staff You will adequately monitor my dose, duration, and indication of use. - I am currently prescribed an antidepressant, initiated 3/1/23 and revised 3/14/24. The related interventions included instructions to staff You will adequately monitor my dose, duration, and indication of use. - I am currently prescribed an antipsychotic medication, initiated and revised on 3/25/24. The related interventions included instructions to staff You will adequately monitor my dose, duration, and indication of use. - I have behavioral symptoms such as choosing not to have care provided: Refuse to allow staff to get me out of bed at times, refuse to allow staff to shower me, (and) sign and symptoms of psychosis, initiated 12/6/23 and revised 3/25/24. The interventions included, I will report and you will observe for changes in my behaviors, determine if any alterations in care plan is needed and You will redirect my behavior when choosing not to have care, initiated 12/6/23. - I have depression as evidenced by change in living environment, chronic pain, (and) progression of disease process, initiated on 3/1/23 and revised on 6/6/23. The interventions instructed staff I will report and you will observe for changes in my depression symptoms. - I have a diagnosis of depression and present with signs/symptoms of depression such as lack of energy, feelings of sadness, behavioral changes of hallucinations and delusions at times, initiated and revised on 3/24/24. This focus did not include an intervention related to staff monitoring for the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 17 of 31 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 03/26/2024 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 0758 resident's signs and symptoms of depression. Level of Harm - Minimal harm or potential for actual harm Review on 3/26/24 at 2:42 p.m. of Resident #59's available assessments showed the assessment for Behaviors was not part of the drop down list, showing that assessment had not been completed for this resident. Residents Affected - Few During an interview on 3/26/24 at 4:53 p.m. the Director of Nursing (DON) stated the facility has a behavior assessment for staff to complete for anything out of the norm (for residents), If they are getting aggressive, (or) yelling. The DON reported Resident #59 typically will hallucinate snakes and frogs. She reviewed Resident #59's record and confirmed no behavior assessment had been completed and was unavailable as an assessment. Can't believe they haven't done one. The DON reported wanting to check with the Regional for the TASK behavior completion as she wasn't aware of the facility doing it. 3. A review of the admission Record revealed Resident #55 was admitted to the facility on [DATE] with diagnoses to included metabolic encephalopathy, generalized anxiety. Further review of the medical record revealed an additional diagnosis of depression. During an interview and observation of Resident #55 in bed on 3/24/24 at 9:08 a.m. the resident confirmed she was in the facility long term and that she hasn't been to any of the activities but stated, This is a great place. Review of the Minimum Data Set assessment, dated 2/2/24, revealed in Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 14, indicating cognitively intact. Section N - Medications showed an antidepressant was administered. Review of the Medication Administration Records (MAR) for February and March 2024 showed: -Duloxetine HCI Oral Capsule Delayed Release Particles 20 MG (milligram) - Give 1 capsule by mouth one time a day for depression, start 1/30/24. This medication was administered as ordered. -Mirtazapine Oral Tablet 7.5 MG - Give 1 tablet by mouth at bedtime for depression, start 1/29/24. This medication was administered as ordered. Review of the February and March 2024 Medication Administration Records (MARs) revealed no physician order or record of behaviors being monitored. Review of a Behavioral Health Note, dated 2/16/24, revealed the primary psychiatric diagnosis code as major depressive disorder. The medical decision section showed: Recommend continuing Remeron as ordered for appetite. The GDR (gradual dose reduction) comments revealed a decline due to risk of decompensation. A review of Resident #55's care plan, initiated on 1/30/24, revealed a Focus as I am currently prescribed an antidepressant medication. The Goal was noted as I will have no adverse side effects from my medication. Interventions included: you will revaluate my medication with any significant change in condition/status, you will routinely evaluate if this medication can be reduced or discontinued. A review of Resident #55's care plan, initiated on 3/24/24, revealed a Focus as I have a diagnosis of depression and present with signs/symptoms of excessive sleeping, tearfulness, anger. The Goal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 18 of 31 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 03/26/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was noted as I will display no major depressive signs/symptoms such as tearfulness or anger outburst. Interventions included: I will receive my medications as ordered, I will receive psych services as needed, you will encourage family involvement and you will provide emotional support and assistance as needed. A review of Resident #55's care plan, initiated on 3/25/24, revealed a Focus as I am at risk for adverse side effects related to my use of an antidepressant medication. Interventions, dated 3/25/24, included: you will observe for changes in my behaviors and revise/update my care plan as needed to support my current status. Review of Resident #55's available assessments showed the assessment for Behaviors was not part of the drop down list, showing that assessment had not been completed for this resident. An interview was conducted with Staff P, Licensed Practical Nurse (LPN) on 3/25/24 at 2:52 p.m. Staff P stated behaviors are under assessments on the behavior sheet. She looked under Resident #55 and stated, I don't see anything under [Resident #55]. An interview was conducted with the Director of Nursing on 3/26/24 at 4:47 p.m. The DON stated the behavior assessment is for anything out of the norm for the yelling, getting anxious. The nurses have a behavior assessment they are supposed to be completing. The DON stated there isn't a batch order for that (behaviors) and the nurses should be monitoring for behaviors and if any behaviors completing the behavior assessments. The DON reviewed the medical record for Resident #55 and there was no behavior assessment completed for Resident #55. Review of the policy titled, Psychoactive Medications/Gradual Dose Reduction (GDR)/ Unnecessary medications policy, revised 4/23, showed, It is the policy of this facility that a resident will receive medications and psychoactive medications only when it is necessary to improve the resident's overall psychosocial health status. To ensure the resident is receiving the necessary medication at the lowest effective dose with an appropriate diagnosis. To ensure gradual dose reduction attempts are made unless contraindicated . 14. Unnecessary Drugs - Every resident's drug regimen is to be free from unnecessary drugs. An unnecessary drug is any drug when used: - Without adequate monitoring; - Demonstrates monitoring for each medication as appropriate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 19 of 31 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 03/26/2024 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, record reviews, and interviews the facility failed to ensure the medication error rate was less than 5.00%. Thirty-two medication administration opportunities were observed and seven errors were identified for three residents (#500, #88, and #41) of five residents observed. These errors constituted a 21.88% medication error rate. Residents Affected - Some Findings included: 1. On 3/24/24 at 4:46 p.m. an observation of medication administration with Staff G, Licensed Practical Nurse (LPN), was conducted with Resident #500. Staff G dispensed the following oral medications: - Ferrous Sulfate 325 milligram (mg) over-the-counter (OTC) tablet - Metformin 500 mg tablet - Oyster Shell Calcium 500 mg plus Vitamin D 5 microgram (mcg) OTC tablet. Staff G confirmed dispensing three oral tablets. Staff G administered the medications and obtained a blood glucose reading of 169 from the resident's left index finger. Staff G returned to the medication cart and removed the resident's Novolog FlexPen. - Novolog insulin aspart Flexpen, Staff G dialed the pen to 2 units, applied a needle, uncapped the needle, entered the resident's room, cleaned the resident's left lower abdominal quadrant with alcohol, and without pinching the skin at the injection site injected the 2 units of insulin. Staff G returned to the medication cart, parked at the doorway of the resident's room and removed a vial of nebulizer medication. - Ipratropium/Albuterol 0.5/3 mg/3 milliliter (mL) vial. Staff G dispensed the vial contents in the medication cup of the nebulizer mask (removed from plastic bag), applied the mask to the resident and turned the nebulizer machine on. Aerosol was observed emitting from the mask. Staff G stayed in the doorway of the room periodically asking the resident if they were okay, and tapping the cup. Staff G removed the mask at 5:20 p.m. and placed the tubing, medication cup, and mask into the plastic bag. Staff G left the room and shut the resident's door then washed hands in the unit's kitchen area. On 3/24/24 at 5:21 p.m., Staff G reported only priming insulin pens when first getting them then questioned if that wasn't right and might have to check to see if education had changed. Staff G stated normally she goes back to the resident and washes the nebulizer equipment, hanging it up to dry. Review of Resident #500's March 2024 Medication Administration Record (MAR) included the following orders and explanations of errors related to the observation: - Oystercal Oral tablet 500 mg - give 1 tablet by mouth two times a day for supplement. The order did not reveal the resident was to be given a combination tablet of Oyster Shell calcium and Vitamin D. The resident was scheduled at 9:00 a.m. and per the MAR had received Cholecalciferol (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 20 of 31 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 03/26/2024 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 1000 mcg (microgram) tablet a day for vitamin/mineral supplement. Level of Harm - Minimal harm or potential for actual harm - Novolog (insulin aspart) per sliding scale subcutaneously with meals. The sliding scaled showed the resident was to receive 2 units for a blood glucose level of 169. Residents Affected - Some According to the manufacturer specifications, located at https://www.novo-pi.com/novolog.pdf and accessed on 3/29/24 at 12:43 p.m, revealed Giving the airshot before each injection. Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing. Review of the facility policy, Administration of Injections, implemented 11/1/23, instructed staff members in the procedure for subcutaneous injections Pinch the skin around the injection site to form a 1 fat fold. - Ipratropium-Albuterol inhalation solution 0.5-2.5 (3 mg/3 mL) - 3 mL inhale orally every 6 hours for respiratory therapy while awake. Review of the facility policy titled, Nebulizer Therapy, implemented 11/1/23, instructed staff members to: 6. Obtain resident's vital signs, and perform respiratory assessment to establish a baseline. The policy revealed staff were to document date, time, duration of therapy, resident vital signs, respiratory assessment, and response to treatment. The observation did not reveal the resident's vital signs were obtained or a respiratory assessment was performed prior to the administration of the nebulized medication. 2. On 3/25/24 at 9:10 a.m. an observation of medication administration with Staff I, LPN was conducted with Resident #88. Staff I dispensed the following medications: - Prostat AWC 30 milliliter (mL) - Acidophillus - Lactobacilli probotic 500 million cells capsule OTC - Vitamin C 500 mg tablet OTC - Benzonatate 200 mg capsule - Cetirizine 10 mg OTC tablet - Vitamin D 25 microgram (mcg) (1000unit) OTC tablet - Citalopram 20 mg tablet - Folic Acid 400 mcg OTC tablet - Guaifenesen Extended Release (ER) 600 mg OTC tablet - Prednisone 20 mg tablet - 2 tabs - Zinc 50 mg OTC tablet (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 21 of 31 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 03/26/2024 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 - Breo Ellipta 100 mcg inhaler (corticosteriod) Level of Harm - Minimal harm or potential for actual harm - Spiriva Resp inhaler (bronchodilator) Residents Affected - Some Staff I confirmed dispensing 11 tablets, 2 inhalers, and one liquid medication. Staff I assisted the resident with the administration of 2 puffs of the bronchodilator Spiriva, the resident refused a drink water, then immediately followed one puff of the corticosteriod inhaler Breo Ellipta. The resident than drank some water, and under the supervision of the Staff I took the oral medications. Review of Resident #88's March 2024 MAR showed the following: - Folic Acid 1 mg tablet by mouth one time a day for supplement. Review of the facility policy titled, Administration of Metered-Dose Inhaler, implemented 11/1/23, instructed staff as: If resident is using a corticosteriod and a bronchodilator administer the bronchodilator first then wait 5 minutes before administering the corticosteriod. 3. On 3/25/24 at 9:20 a.m. an observation of medication administration with Staff C, LPN was conducted with Resident #41. Staff C dispensed the following medications: - Amlodipine 10 mg tablet - Furosemide 40 mg tablet - Oxtbutynin Extended Release (ER) 5 mg tablet - Losartan Potassium 25 mg tablet - Gababentin 100 mg capsule - Calcium with Vitamin D 600 mg/10 mcg OTC tablet - Magnesium oxide 400 mg OTC tablet - Fish oil 1000 mg OTC softgel - Multi Vitamin with mineral OTC tablet Staff C confirmed dispensing 9 tablets/capsules. Staff C administered all medications to the resident at one time per the preference of the resident and then offered water, which was accepted. Review of Resident #41's March 2024 MAR revealed the following: - Calcium - Vitamin D3 600-12.5 mg/mcg capsule - Give 1 capsule by mouth one time a day for dietary supplement. - Multiple Vitamin tablet - Give 1 tablet by mouth one time a day for supplementation. During an interview and review of the medication errors conducted, the Director of Nursing on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 22 of 31 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 03/26/2024 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 - Some 3/26/24 at 5:37 p.m., stated staff needed to read (the orders) and make sure they were giving the right medications. The amount of the available OTC medications was discussed and the DON stated they were going to have to work on that. She stated medication administration should be done in accordance with policy. The DON reported, on 3/26/24 at 5:29 p.m. priming of an insulin pen should be done prior to each injection and she reviewed the policy for nebulizer medication and stated the assessment would be added to the order. Review of the policy titled, Medication Administration, implemented 3/14/24, revealed: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. The compliance guidelines included: 8. Obtain and record vital signs when applicable or per physician orders. When applicable, hold medication for those vital signs outside their physicians prescribed parameters. 10. Ensure that the six rights of medication administration are followed: a. Right resident b. Right drug c. Right dosage d. Right route e. Right time f. Right documentation 11. Review MAR to identify medication to be administered. 12. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication, form, dose, route, and time. 15. Administer medication as ordered in accordance with manufacturer specifications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 23 of 31 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 03/26/2024 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 - Some 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to ensure one of one treatment cart on the 600 unit was locked while unattended, failed to ensure medications on one medication cart (600) of five medication carts were not accessible to unauthorized personnel, failed to ensure one medication room (400) out of three medication rooms contained a locked permanently affixed controlled substance refrigerator box, and failed to ensure medications with a limited life were dated when opened on two of three sampled medication carts. Findings included: On 3/23/24 at 9:43 a.m. an observation revealed an unlocked and unattended treatment cart parked in an alcove next to the 600-unit shower room. Staff K, Certified Nursing Assistant (CNA) arrived at the area during the observation and stated the process was when a cart was observed unlocked to go tell the nurse. (Photographic Evidence Obtained) On 3/23/24 at 9:46 a.m. Staff F, Licensed Practical Nurse (LPN) reported not looking at the treatment cart yet today, at 9:48 a.m. the staff member observed the unlocked treatment cart and confirmed it should be locked. On 3/23/24 at 3:53 p.m. an observation was made of seven over-the-counter (OTC) medication bottles sitting on top of an unattended medication cart parked on the 600 hallway with three unknown CNAs standing nearby. Staff L, Registered Nurse (RN) came out of room [ROOM NUMBER] after photographic evidence had been obtained and confirmed the bottles should not be out, just magnesium, iron, and vitamins. Staff L reported leaving the bottles out because of having to continually grab them. (Photographic Evidence Obtained) On 3/26/24 at 11:13 a.m. an observation with Staff C, LPN, was conducted of the 500/400 medication cart. The observation revealed one Levemir FlexPen contained in a bag labeled 3/17 and read to Discard 42 days after open. The pen was not labeled with an open date. One Levemir FlexPen was observed without an open date on either the bag or pen. Staff C confirmed the pen had been opened. On 3/26/24 at 11:27 a.m. an observation with Staff I, LPN, revealed an unattached locked Emergency Drug Kit (EDK) inside the refrigerator of the 400-unit medication room. The box was able to be placed on the counter of the room and contained three vials of the controlled substance Ativan. The Nursing Home Administrator was able to confirm the findings. (Photographic Evidence Obtained) On 3/26/24 at 11:36 a.m. an observation with Staff M, LPN, of the 400 Front Cart 2 revealed an opened Levemir FlexPen. Staff M confirmed the findings and asked if it would be okay to write the date opened with a [marker] on the outside of the pen. An interview was conducted with the Director of Nursing on 3/26/24 at 5:23 p.m. The DON stated carts are to be locked when unattended, never should medications be left on top of the med cart, and insulin pens should have been dated. The DON stated the lock box inside the 400-unit refrigerator had been fixed and the Lorazepam (Ativan) EDK should have been in the 700-unit's locked affixed box. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 24 of 31 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 03/26/2024 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 The policy titled, Guidelines for Medication Storage and Labeling, revised 10/22, revealed, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Residents Affected - Some 1. Medications and biologicals and medication rooms, carts, and refrigerators are maintained within: a. Secured (locked) locations, accessible only to designated staff; b. kept in clean and sanitary conditions; c. temperatures are maintained in corns with manufacturer specifications and monitored according to national guidelines which is 36 - 46°F. 3. Schedule II controlled medications (excluding single-unit packaging in minimum quantities that can be readily detected if missing) are maintained within a separately locked permanently affixed compartment. All controlled drugs are stored under double lock and key. 9. Multi-dose vials that have been opened or accessed (e.g. needle-punctured) should be dated when the file is first accessed and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. 11. Insulin pens containing multiple doses of insulin are meant for a single-resident use only, and must never be used for more than one person, even when the needle is changed; Insulin pens must be clearly labeled with the resident's name and other identifier(s) to verify that the correct pen is used on the correct resident; insulin pens should be stored in a sanitary manner to prevent cross contamination. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 25 of 31 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 03/26/2024 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review the facility failed to maintain one ice machine (400 hall) of three facility ice machines in a sanitary manner. Residents Affected - Few Findings included: An observation on 3/26/24 at 12:13 p.m. of the ice machine located in the locked nourishment room on the 400 hall revealed multiple spots of black bio growth on the top of the inside of the ice bin when the cover was lifted. During an interview, at this time, Staff M, Licensed Practical Nurse stated the ice was used by CNAs (certified nursing assistants) to put in the cups for residents. The ice machine was observed to be full of ice. He confirmed maintenance was responsible for cleaning the ice machines. On 3/26/24 at 12:20 p.m. the Maintenance Director stated the ice machine (400 hall) was last cleaned in the November/December 2023 timeframe. He observed and confirmed the black bio growth located inside the ice machine. He stated the staff should have let him know, and they should have entered a work order in the electronic work order system. He said if he would have seen it, he would have cleaned it. He stated he would look to see if any work orders were submitted from January 2024 to today. On 3/26/24 at 1:06 p.m. the Nursing Home Administrator confirmed there were no work orders submitted. Review of the facility policy titled, CLEANING OF ICE MACHINES, revised 6/21, revealed the purpose as: Ice may become contaminated from the use of impure water, contamination of ice-making machines, or from improper storage or handling of ice .The ice machine will be drained, cleaned and sanitized according to manufacturer's specification. Review of the facility policy titled, Safe and Homelike Environment, dated 11/01/2023, revealed the Policy as: In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible . Policy Explanation and Compliance Guidelines: 3. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 26 of 31 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 03/26/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 3/23/24 at 9:35 a.m., Staff G, Licensed Practical Nurse (LPN) reported Resident #220 was on Contact precautions due to Clostridium difficile (C-Diff). The observation of Resident #220's room showed a caddy hanging from the door with a word search puzzle, a box of gloves, a box for a stethoscope, and a box of facial masks. The sign posted on the caddy was turned away from the viewer and had to be turned around to show the room was under Contact Precautions. The sign read : Residents Affected - Some Stop Contact Precautions Visitors: Stop at Nurses Station Before Entering. Wear gloves upon entering the room. Wear a gown upon entering the room. Wash hands, before and after patient or environment contact, with soap and water or alcohol-based hand rinse. On 3/23/24 at 10:05 a.m. Staff H, LPN, was observed entering Resident #220's room without donning any PPE (gowns were not available). Staff H stepped into the room and began speaking with the resident, Staff H then shut the door to the room while remaining inside. On 3/23/24 at 10:08 a.m. an observation showed the caddy hanging from the door of Resident #220's room did not contain any gowns related to the instructed use of necessary Personal Protective Equipment (PPE). An interview was conducted with Staff G, LPN on 3/23/24 at 10:09 a.m. who reported gowns, gloves, and mask should be worn whenever entering Resident #220's room. Staff G stated the lack of PPE was noticed earlier today of one gown, so was told they (gowns) were in transit from central supply. On 3/23/24 at 10:11 a.m., Staff N, Unit Manager was observed filling Resident #220's PPE caddy with gowns. Staff N stated staff should wear gowns, gloves, and masks prior to entering the room. Staff N confirmed there were no gowns available prior to her just stocking them. Staff N stated there should also be a dedicated blood pressure cuff. On 3/23/24 at 10:22 a.m., Staff H, LPN left Resident #220's room, washing hands at a nearby sink. Staff H confirmed entering the resident's room without PPE. Staff H stated she wasn't meaning to that she was just going to tell the resident of seeing family member at a local store. Staff H stated, Have to own it. Review of Resident #220's admission Record revealed the resident was admitted on [DATE] and re-admitted on [DATE]. The record included diagnoses of Enterocolitis due to Clostridium Difficile not specified as recurrent, unspecified myelodysplastic syndrome, gastrostomy status, and adult failure to thrive. Review of Resident #220's Order Summary Report showed an order: Isolation: Contact every shift for C-Diff until 4/1/24, initial start 3/22/24, ordered 3/24/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 27 of 31 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 03/26/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #220's AHCA-3008, dated 3/21/24, revealed the resident was being transferred to this facility from an acute care facility with Contact precautions related to C-Diff. Review of Resident #220's care plan revealed the resident was symptomatic for C-Diff and was at risk for complications. Further review of the care plan showed the resident required Contact isolation related to C-Diff. Review of the Centers of Disease Control and Prevention guidance - Prevent the Spread of C.diff , located at .https://www.cdc.gov/C.diff/prevent.html and accessed on 3/29/24 at 7:01 p.m., revealed C.diff germs are carried from person to person in poop. C-diff can also live on people's skin. People who touch an infected person's skin can pick up the germs on their hands. Taking a shower with soap and water can reduce the C.diff on your skin and lessen the chance of it spreading. Washing with soap and water is the best way to prevent the spread from person to person. The CDC explained on how to inhibit the spread of C-diff in a healthcare setting was While caring for you and other patients with C.diff, healthcare professionals will use certain precautions, such as wearing a gown and gloves, to prevent the spread of C.diff to themselves and to other patients. 4. On 3/24/24 at 4:46 p.m. Staff G, LPN, was observed for administration of medications with Resident #500. Staff G administered oral and subcutaneous medications then placed the contents of a 3 milliliter (mL) Ipratropium/Albuterol vial into the medication cup attached to a nebulizer mask removed from a drawstring plastic bag. After the completion of the administration, Staff G removed the aerosol mask and placed it and the medication cup into the plastic bag. Staff G left the room, washed hands in the nearby kitchen area, and shut the resident's door. During an interview on 3/24/24 at 5:21 p.m. Staff G stated she normally goes back and washes the nebulizer equipment and then hangs it up to dry. Review of the policy titled, Nebulizer Therapy, implemented 11/1/23, revealed, It is the policy of this facility for nebulizer treatments, once ordered, to be administered by nursing staff as directed using proper technique and standard precautions. If the nebulizer will supply oxygen to the patient, referred to the policy oxygen concentrator. The compliance guidelines care of the equipment revealed: 1. Clean after each use. 2. Wash hands before handling equipment. 3. Disassemble parts after every treatment. 4. Rinse the nebulizer cup in mouthpiece with sterile or distilled water. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 28 of 31 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 03/26/2024 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 0880 5. Level of Harm - Minimal harm or potential for actual harm Shake off excess water. 6. Residents Affected - Some Air dry on an absorbent towel. 7. Once completely dry, store the nebulizer cup and the mouthpiece in a zip lock bag. 8. Change nebulizer tubing weekly. 9. Periodically disinfect unit per manufacturers recommendations. Based on observations, interviews, and record reviews, the facility failed to develop and maintain an effective infection prevention and control program to control the spread of infection by failing to ensure staff members (A, B and H) donned appropriate personal protective equipment (PPE) before entering the rooms of residents under transmission based precautions for three residents (#319, #320, and #220) of four residents in the facility under transmission based precautions and failed to clean the nebulizer after use for one resident (#500) of three residents observed for medication administration. Findings included: 1. A review of Resident #319's physician's orders revealed Resident #319 was admitted to the facility on [DATE] with diagnoses of sepsis and pneumonia. A diagnosis of resistance to multiple antimicrobial drugs was added on 3/18/2024. A review of Resident #319's physician's orders revealed the following orders: - An order, dated 3/21/2024, for gentamicin in saline 1 milligram (mg)/1 milliliter (ml) intravenously (IV) every 12 hours for urinary tract infection until 3/26/2024. - An order, dated 3/21/2024 for contact isolation every shift for multi-drug resistant organism (MDRO). An observation was conducted on 3/23/2024 at 9:55 a.m. outside of Resident #319's room. An isolation caddy containing isolation gowns, gloves, and surgical masks was observed hanging on the door to Resident #319's room with signage posted on the caddy indicating Resident #319 was on contact isolation precautions. The posted signage had printed instructions, wear gloves upon entering this room, and wear a gown upon entering this room. Staff A, Certified Nursing Assistant (CNA) was observed entering Resident #319's room. Staff A, CNA was not observed donning an isolation gown or gloves upon entering Resident #319's room. Following the observation, an interview was conducted with Staff A, CNA. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 29 of 31 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 03/26/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Staff A, CNA stated she was passing water to Resident #319 and saw the isolation caddy and signage indicating the resident was on contact isolation precautions. Staff A, CNA did not explain why she did not don an isolation gown and gloves before entering the room. 2. A review of Resident #320's admission Record revealed Resident #320 was admitted to the facility on [DATE] with diagnoses of acute respiratory failure, pneumonia, and chronic obstructive pulmonary disease. A diagnosis of COVID-19 was added on 3/22/2024. A review of Resident #320's physician's orders revealed an order, dated 3/24/2024, for droplet isolation precautions every shift for COVID-19. An observation was conducted on 3/25/2024 outside of Resident #320's room. An isolation caddy containing N95 respirator masks, face shields, isolation gowns, and gloves was observed hanging on the door to Resident #320's room with signage posted on the caddy indicating Resident #320 was on droplet isolation precautions. The posted signage had printed instructions, wear gloves upon entering this room, wear a gown upon entering this room, and wear a surgical mask (N95 is available) upon entering this room. Staff B, CNA was observed inside of Resident #320's room. Staff B, CNA was observed wearing an N95 respirator mask inside of Resident #320's room. Staff B, CNA was not observed wearing an isolation gown, gloves, or eye protection when inside of Resident #320's room. Following the observation, an interview was conducted with Staff B, CNA. Staff B, CNA stated Resident #320 tested positive for COVID-19 and staff should don a gown, eye protection, gloves, and an N95 mask when entering the room. Staff B, CNA addressed she did not don gloves, an isolation gown, or eye protection before entering Resident #320's room, stating, I probably should have done that. An interview was conducted on 3/26/2024 at 2:43 p.m. with the Infection Preventionist (IP). The IP stated when a resident is placed on transmission based precautions, a caddy with the appropriate PPE is placed on the resident's door along with the appropriate signage to indicate the type of transmission based precautions the resident is on. The IP also stated she would expect staff to use the PPE provided any time they are entering the room for their own safety and for the safety of the residents. The IP stated for a resident with COVID-19, staff should be donning an N95 respirator mask, eye protection, an isolation gown, and gloves before entering the resident's room. If a resident is on contact isolation precautions, staff should don an isolation gown and gloves before entering the resident's room. The IP stated, It is unacceptable for staff to not don the appropriate PPE when entering the room of a resident on transmission based precautions. An interview was conducted on 3/26/2024 at 5:08 p.m. with the Director of Nursing (DON). The DON stated she would expect staff to follow the facility policy regarding residents on transmission based precautions. A review of the facility policy titled, Infection Prevention and Control Program (IPCP), last revised in September 2022, revealed under the section titled Policy, the facility has developed and maintains an infection prevention and control program that provides a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. The policy also revealed under the section titled Implementation of Transmission-Based Precautions, when a resident is placed on transmission-based precautions, facility staff should don appropriate PPE before or upon entry into the environment of a resident on transmission-based precautions. The policy revealed under the section titled Contact Precautions, contact precautions are intended to prevent transmission of pathogens that are spread by direct or indirect contact with the resident or environment, and requires the use of appropriate PPE, including a gown and gloves before or upon (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 30 of 31 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 03/26/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some entering the room or cubicle. The policy also revealed under the section titled Droplet Precautions, the use of droplet precautions applies when respiratory droplets contain pathogens which may be spread to another susceptible individual. Facemasks should be used upon entry into a resident's room or cubicle with respiratory droplet precautions. Based upon the pathogen or clinical syndrome, if there is risk of exposure of mucous membranes or substantial spraying of respiratory secretions is anticipated, gloves and gown as well as goggles (or face shield) should be worn. (Photographic Evidence Obtained) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106086 If continuation sheet Page 31 of 31