Inspection·January 29, 2026

N0000 | INITIAL COMMENTS | N0000 | | 02/05/2026

N0101 SS = D | Resident Medical Records CFR(s): 400.1411(j), FS; 59A-4.118(2), FAC 400.1411(j) | N0101 | Facility Response | 02/28/2026 An unannounced re-licensure survey was conducted at Freedom Pointe Health Center on January 26, 2026, through January 29, 2026. Deficient practice was identified at the time of the survey. Keep full records of resident admissions and discharges; medical and general health status, including medical records, personal and social history, and identity and address of next of kin or other persons who may have responsibility for the affairs of the resident; and individual resident care plans, including, but not limited to, prescribed services, service frequency and duration, and service goals. The records must be open to agency inspection. The licensee shall maintain clinical records on each resident in accordance with accepted professional standards and practices, which must be complete, accurately documented, readily accessible, and systematically organized. 59A-4.118(2) FAC Each medical record must contain sufficient information to clearly identify the resident, his or her diagnosis and treatment, and results. This LICENSURE REQUIREMENT is NOT MET as evidenced by: Based on interview and record review the facility failed to ensure residents' records were complete and accurate for documentation of provider notification when physician orders are not followed as prescribed for 2 of 6 residents, Residents #5 and #15, reviewed for medication management. Findings include: This plan of correction for the above reference facility is in response to the Statement of Deficiencies. While this document is being submitted as confirmation of the facilities on-going efforts to comply with all statutory and regulatory requirements, it should not be construed as an admission or agreement with the findings and document outlines specific actions in response to the identified issues. We have not provided a detailed response to each allegation or findings, nor have we identified mitigating factors.

F0842 Resident Record – Identifiable Information Corrective action for residents noted to have been affected by the deficient practice. Resident #5 medication administration records reviewed by DON on 1/27/2026. Physician notified by RN on 1/27/2026 of administration discrepancy. New administration parameter orders were received and implemented. Resident medical records were updated to reflect order updates and physician notification. Care plan reviewed and updated as indicated. Physician completed medication regimen review for appropriateness and safety on 1/27/2026. Resident #15 pain medication administration records reviewed by DON on 1/27/2026. Physician was notified by RN on 1/27/2026 of administration Office of Primary Care and Health Systems Management STATE FORM Florida Department of Health 130471043 01/29/2026 FREEDOM POINTE HEALTH CENTER 1460 EL CAMINO REAL DRIVE, THE VILLAGES, Florida, 32159 PREFIX TAG ID PREFIX TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETION DATE

N0101 SS = D Continued from page 1 1) Review of Resident #5's physician order dated 12/15/2025 read, "Carvedilol Oral Tablet 12.5 MG [Miligram] (Carvedilol) Give 1 tablet by mouth two times a day for HTN [Hypertension]." Review of Resident #5's Medication Administrator Record (MAR) for the month of January 2026 for Carvedilol 12.5 MG documented on 1/10/2026 at 1700 (5:00PM) blood pressure 119/58, Pulse 84, coded "4" [vital signs outside of parameters], dated 1/17/2026 at 1700 no blood pressure or pulse was documented, coded "5" (Hold/See Nurse Note), dated 1/18/2026 at 1700 blood pressure 109/52, Pulse 84, coded "4" [vital signs outside of parameters], dated 1/22/2026 at 1700 blood pressure 100/73, Pulse 82, coded "4", dated 1/24/2026 at 0900 (9:00AM) no blood pressure or pulse documented, coded "4" and 1/27/2026 at 104/57, no blood pressure or pulse documented, coded "4" on 0900 no blood pressure or pulse documented, coded "4". Review of Resident #5's progress note dated 1/17/2026 read, "Held medication, BP [Blood Pressure] 108/50." Review of Resident #5's progress note dated 1/18/2026 did not contain documentation related to the resident's Carvedilol not being administered. Review of Resident #5's progress notes for the period of 01/10/2026 through 01/25/2026 did not contain documentation the physician was notified the resident's Carvedilol was not administered. During an interview on 1/28/2026 at 7:52 AM the Director of Nursing (DON) stated, "I would expect nursing staff if they were going to 'hold a medication that does not have parameters and they have spoken to the provider they should document it in the record that they spoke to the provider." During an interview on 1/28/2026 at 1:59 PM Staff E Licensed Practical Nurse (LPN) stated, "If the resident's blood pressure is low, I will hold the medication and notify the provider. I should have documented in the progress notes that I contacted the provider, but I do not think I did." During an interview on 1/28/2026 at 5:00PM with Staff F, LPN, stated, "Sometimes [Resident #5's name] representative will not want the medication to be administered and if the blood pressure is low, I will hold the medication. I will always contact her [Resident #5's] provider to let him know. I do not think I documented the notification in the system."

N0101 Continued from page 1 outside of prescribed parameters. New administration parameters obtained, and documentation of orders and physician notification were completed in resident records. The resident care plan was reviewed and updated as indicated. Physician completed medication regimen review for appropriateness and safety on 1/27/2026 How will the facility identify other residents having the potential to be affected by the same deficient practice? Residents requiring the use of PRN medication, administration parameters, and/or medication holding instructions have the potential to be affected by the identified practice. Community review completed by community interdisciplinary team on 1/27/2026. Physician notified of residents requiring clarification of medication administration and/or hold parameter orders. Orders and documentation in resident's medical record. Care plans for identified residents were reviewed and updated as indicated. The measures the facility will take or systems the facility will alter to ensure that the problem will be corrected and will not reoccur. Current licensed clinical associates will be re-educated by the community Director of Nursing or designee before 2/28/2026 or prior to working next scheduled shift on community Medication Administration policy, Charting and Documentation policy, and community process of follow physician orders, community process for physician notification of omitted medication administration. New physician orders are routinely reviewed during morning clinical meetings by the interdisciplinary team to validate completion of transcription or need of clarifying parameters. If discrepancies are identified, immediate physician notification completed and one on one education provided when indicated. Missed and Held medication reports routinely reviewed during morning clinical meeting my interdisciplinary team to verify medication administration parameters are STATE FORM Florida Department of Health PRINTED: 04/07/2026 01/29/2026 FREEDOM POINTE HEALTH CENTER 1460 EL CAMINO REAL DRIVE, THE VILLAGES, Florida, 32159 PREFIX PREFIX CROSS-REFERENCED TO THE COMPLETION DATE

N0101 Continued from page 2 SS = D During an interview on 1/29/2026 at 10:43 AM Medical Doctor #4 stated, "The staff call me to notify when they are going to hold (Resident #5's name) medication." 2) Review of Resident #15's physician order dated 1/8/2026 read, "Oxycodone HCl Oral Tablet 5 MG (Milligram) give 1 tablet by mouth every 8 hours as needed for Acute Pain (7-10)." Review of Resident #15's MAR for the month of January 2026 documented Oxycodone 5 mg was administered on 1/6/2026 at 1248 12:48 PM pain level 6, dated 1/17/2026 at 1757 12:57PM pain level 6, dated 1/20/2026 at 2110 9:10 PM pain level 6, dated 1/21/2026 at 0652 6:52 AM) pain level 5, dated 1/24/2026 at 1929 (7:29 PM) pain level 2, dated 1/25/2026 at 1236 (12:36 PM) pain level 4, and dated 2117 (9:17 PM) pain level 4. Review of Resident #15's progress notes did not contain documentation of provider notification regarding oxycodone being administered when the pain level was below the physician ordered parameters. During an interview on 1/27/2026 at 3:45 PM Staff A, LPN, stated, "I was giving her oxycodone before her wound care changes. She (Resident #15) likes to take that medication to handle the pain. The doctor is aware that this is the resident's preference." During an interview on 1/28/2026 at 7:48AM the Director of Nursing stated, "If the medication is outside parameters the staff need to speak to the provider and write a note and document they spoke to the provider." During an interview on 1/28/2026 at 1:159 PM Staff E, LPN, stated, "I cannot recall , but I normally will not hold a medication that does not have parameters without contacting the provider." During an interview on 1/28/2026 at 5:00 PM Staff F, LPN, stated, "I am new and still learning the system. I think I wrote the pain level wrong in that section." During an interview on 1/29/2026 at 10:17AM APRN # 1 stated, "The staff call me about Resident #15's pain medication and request from the patient." Review of the facility policy and procedure titled "Administering Medications" with a last review date of 9/23/2025 read, "Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation." N0101 Continued from page 2 being followed and required physician notification completed. If discrepancies are identified, immediate corrective action is completed and one on one education provided when indicated. Monthly medication order reviews will be completed by community Consultant Pharmacist for identification of order discrepancies. Results of routine reviews will be provided reviewed by the community Director of Nursing. Routine weekly reviews will be completed by the Director of Nursing on medication administration specific to orders with administration parameters for 5 randomly selected residents for 6 weeks and then monthly for 3 months. Quality Assurance Plans to monitor facility compliance to make sure that corrections are achieved and permanent. Monthly review of completed physician order reviews, Missed/Held administration reports and monthly Consultant Pharmacist review results and trends will be completed by the Director of Nursing or designee and reported to the facility's QAPI committee for the next 3 months and then re-evaluated to determine if further monitoring is indicated. Florida Department of Health 130471043 01/29/2026 1460 EL CAMINO REAL DRIVE, THE VILLAGES, Florida, 32159 CROSS-REFERENCED TO THE DATE

N0101 SS = D Continued from page 3 4. Medication are administered in accordance with prescriber orders, including any required time frame.* Review of the facility policy and procedure titled 'Charting and Documentation' with a last review date of 9/23/2025 read, "Policy Statement: All services provided to the resident, progress toward the care pan goals, or any changes in the resident's medical physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Policy Interpretation and Implementation. 3. Documentation in the medical record will be the objective (not opinionated or speculative), complete, and accurate.' Class III Right to Adequate and Appropriate Health Care CFR§: 400.022(1)(1), FS (1) The right to receive adequate and appropriate health care and protective and support services, including social services; mental health services, if available; planned recreational activities; and therapeutic and rehabilitative activities consistent with the resident care plan, with established and recognized practice standards within the community, and with rules as adopted by the agency. This LICENSURE REQUIREMENT IS NOT MET as evidenced by: Based on observation, interview, and record review the facility failed professional standards for care for wound care for 3 (Resident #4, Resident #15, and #40) of 4 residents reviewed for skin conditions and facility failed to perform hand hygiene during wound care for 1 (Resident #15) of 4 residents reviewed for skin conditions. Findings include: Findings include: 1) During an observation on 1/26/2026 at 9:45 AM Resident #15 had a wound gauze dressing wrapped to the left upper arm that was not dated. During an interview on 1/26/2026 at 9:45 AM Resident #15 stated, "The wound vac [vacuum, used to treat wounds] is not connected because when they were going N0101 02/28/2026

N0201 SS = D Right to Adequate and Appropriate Health Care CFR§: 400.022(1)(1), FS (1) The right to receive adequate and appropriate health care and protective and support services, including social services; mental health services, if available; planned recreational activities; and therapeutic and rehabilitative activities consistent with the resident care plan, with established and recognized practice standards within the community, and with rules as adopted by the agency. This LICENSURE REQUIREMENT IS NOT MET as evidenced by: Based on observation, interview, and record review the facility failed professional standards for care for wound care for 3 (Resident #4, Resident #15, and #40) of 4 residents reviewed for skin conditions and facility failed to perform hand hygiene during wound care for 1 (Resident #15) of 4 residents reviewed for skin conditions. Findings include: Findings include: 1) During an observation on 1/26/2026 at 9:45 AM Resident #15 had a wound gauze dressing wrapped to the left upper arm that was not dated. During an interview on 1/26/2026 at 9:45 AM Resident #15 stated, "The wound vac [vacuum, used to treat wounds] is not connected because when they were going N0201 Facility Response This plan of correction for the above reference facility is in response to the Statement of Deficiencies. While this document is being submitted as confirmation of the facilities on-going efforts to comply with all statutory and regulatory requirements, it should not be construed as an admission or agreement with the findings and conclusions in the Statement of Deficiencies. This document outlines specific actions in response to the identified issues. We have not provided a detailed response to each allegation or findings, nor have we identified mitigating factors.

F 684 Quality of Care N0201 Corrective action for residents noted to have been affected by the deficient practice. Resident #15 re-evaluation of resident current wound status was completed by DON 1/26/2026. No adverse effects noted. Wound vac was changed per physician orders using appropriate infection control procedure by RN on 1/26/2026. ARNP notified of identified discrepancy with completion of routine dressing change. Resident #15 care plan was reviewed and updated as indicated. Resident #4 current wound was re-evaluated 02/28/2026 1460 EL CAMINO REAL DRIVE, THE VILLAGES, Florida, 32159

N0201 SS = D Continued from page 4 to change it, they realized they did not have supplies for the suction. N0201 Continued from page 4 by DON on 1/26/2026. No adverse effect noted from evaluation. Findings were documented in resident's electronic medical record. Physician notified of findings by LPN on 1/27/26. New orders received per physician and implemented on 1/26/2026. Care plan reviewed and updated as indicated. Review of Resident #15's physician order dated 1/9/2026 read, 'Cleanse, NPWT [Negative Pressure Wound Therapy] to Left Axilla @ 125 mmhg [at 125 milliliters of mercury] pressure. Remove dressing, cleanse wound with Dakins, apply skin prep to peri-wound area, apply drape to peri-wound area. Fill wound space with black foam, cover with drape. Do not apply foam directly to skin without drape barrier. Change dressing 3x [times] weekly, every day shift every Mon (Monday), Wed (Wednesday), Fri (Friday) and as needed for compromised drg [dressing] seal integrity. Monitor NPWT to left axilla and cancelster. Notify MD [Medical Doctor] for s/s [signs/symptoms] of bleeding. If dressing is unable to maintain pressure, check for leakage and reinforce. If problem persists, remove and change dressing. When machine malfunctions and unable to fix it: remove granufloam, pack wound loosely with moist gauze, secure with secondary dressing and notify wound team every shift. Do not leave granufloam longer than 2 hours without a well functioning wound vac machine.' Resident #40 current wound was re-evaluated by DON on 1/27/2026. No adverse effect noted from evaluation. Findings were documented in resident's electronic medical record. Physician notified of findings by LPN on 1/27/26. New orders received per physician and implemented on 1/27/2026. Care plan reviewed and updated as indicated. Review of Resident #15's Treatment Administration Record for the month of January 2026 read, 'Cleanse NPWT to left Axilla.' Documented on 1/23/2022 the order was coded with a '9' [other/see nurse notes]. Review of Resident #15's progress noted dated 1/23/2026 read, 'Awaiting Supplies.' How will the facility identify other residents having the potential to be affected by the same deficient practice? During an interview on 1/27/2026 at 3:45 PM Staff A, Licensed Practical Nurse (LPN) stated, 'We had to change the dressing, and we needed the suction and there were no supplies for the wound vac. The wound nurse is responsible for ordering supplies for the vacuum. I went to look and the wound care nurse was on vacation, and I went to his office. I notified both Unit Managers that we did not have the supplies to change [Resident #15] dressing. My Unit Manager told me not to remove the dressing and wait for the supplies. The dressing was intact, that is why we did not remove it and the vacuum was working properly. We left the vacuum connected with the suction. [Staff B Registered Nurse's name] is the Unit Manager. The resident agreed to leave the dressing in as because if I remove it, we would not be able to put the vacuum back on and it would be a regular dressing. I don't know if she [Staff B] notified the provider.' Residents currently residing in the community have the potential to be affected by the alleged practice. Community wide skin sweep completed by community clinical interdisciplinary team on 1/27/2026. No further residents identified as being affected. During an interview on 1/27/2026 at 4:00 PM Director of Nursing (DON) stated, 'I was not aware of that [wound vac dressing was not changed due to not The measures the facility will take or systems the facility will alter to ensure that the problem will be corrected and will not reoccur. Current licensed clinical associates will be re-educated by the Director of nursing or designee on or before 2/28/2026 or prior to working next scheduled shift on community process for timely implementation of physician orders, required wound care documentation, physician notification, and event reporting and on community Skin Tear policy and Negative Pressure Wound Therapy policy. Residents identified as being admitted or having a newly acquired alteration in skin integrity will be reviewed during routine clinical meeting by the clinical interdisciplinary team to validate completion of required physician notification, order transcription, and assessment documentation. If discrepancies are identified, immediate corrective action will Florida Department of Health PRINTED: 04/07/2026

N0201 SS = D Continued from page 5 Continued from page 5 having supplies]. The wound care nurse is on vacation. It is not likely they did not have supplies, not normal here. Typically, the staff would have let me know. I need to look into what happened. During weekly risk review meetings, the interdisciplinary team will review the clinical record of residents with new skin events. The review will be documented in the resident medical record. During an interview on 1/28/2026 at 7:48 AM the DON stated, "Supplies were here in the overflow storage, and the nurse was not sure where the supplies were located. I could expect them to notify the provider." Routine weekly review will be completed by Director of Nursing for 5 randomly selected residents identified with skin alterations requiring dressing changes or NPWT to verify completion of physician ordered treatment for six weeks and then monthly for 3 months. During an interview on 1/29/2026 at 9:50 AM Staff, R, RN (Registered Nurse) Unit Manager, stated, "We were going to change [Resident #15's name] dressing and we did not have supplies to do the dressing change. We went to the supply room and were unable to locate the supplies. I did not call the provider, the 3-11 supervisor was aware, and we spoke to the resident, and she was okay with leaving the dressing how it was. It was functioning correctly at that time. The supervisor was going to follow up after that." Quality Assurance Plans to monitor facility compliance to make sure that corrections are achieved and permanent. During an interview on 1/29/2026 at 10:07 AM Medical Doctor #1 stated, "I did not know what was going on with the wound vac. If they did not have supplies, they would need to keep it closed until they have supplies again. I was not aware of it." Monthly review of completed routine audit results and trends will be completed by the Director of Nursing or designee and reported to the facility's QAPI committee for the next 3 months and then re-evaluated to determine if further monitoring is indicated. During an interview on 1/29/2026 at 10:17 AM the Advance Practice Registered Nurse (APRN #1) stated, "The staff called me and I gave instructions to change the dressing and to Friday evening [01/23/2026] to a wet to dry dressing."

F880 Infection Control During an interview on 1/29/2026 at 12:14 PM the DON stated, "The staff did not change the dressing on Friday [1/23/2026]. The change the dressing was scheduled on Saturday [1/24/2026]. The dressing the suctioning was malfunctioning and the staff changed the dressing to moist dressing. They should have called me and double checked for supplies. The supplies were available but in the overflow storage. If the staff were unable to change the dressing they should have contacted the provider. The night shift nurse did not contact the provider on Friday [1/23/2026]. The dressing should also have been dated when it was changed on 1/24/2026." Corrective action for residents noted to have been affected by the deficient practice. Review of the facility policy and procedure titled "Negative Pressure Wound Therapy" with a last review date of 9/23/2025 read, "Purpose: The purpose of this procedure is to provide guidelines for establishing and maintain negative pressure wound therapy (NPWT). General Guidelines: 3. Change dressings per physician orders and manufacturer guidelines." Resident #15 re-evaluation of resident current wound status was completed by DON 1/29/2026. No adverse effects noted. Wound vac was changed per physician orders using appropriate infection control procedure by RN on 1/29/2026. Physician notified. How will the facility identify other residents having the potential to be affected by the same deficient practice? Residents currently residing in the community requiring wound care and dressing changes have the potential to be affected by the identified interdisciplinary team review completed with community team on 1/29/2026. No further residents identified as being affected by the cited Florida Department of Health 130471043 01/29/2026 1460 EL CAMINO REAL DRIVE, THE VILLAGES, Florida, 32159 PREFIX PREFIX CROSS-REFERENCED TO THE COMPLETION DATE

N0201 SS = D Continued from page 6 2) During an observation on 1/26/2026 at 11:00 AM Resident #4 had a wound dressing to the left forearm. The wound dressing was not dated. [Photographic evidence obtained] During an interview on 1/26/2026 at 11:00 AM Resident #4 stated, "This happened (dressing on left forearm} while I was in the exercise room and it [the wound dressing has not been changed in about a week." Review of Resident #4's physician orders did not document an order for the resident's left forearm. Review of Resident #4's medical record, the record did not contain documentation of the resident having suffered an injury resulting in a wound to the left forearm. During an observation on 1/27/2026 at 3:55 PM Staff C, RN of Resident #4, the resident was living in bed and to his left arm there was a dressing dated 1/28/2026. Staff C peeled off the dressing corner of the dressing and there was a skin tear. Staff C placed the dressing back on Resident #4's arm. During an interview on 1/27/2026 at 4:00 PM Staff C, RN stated, "I do not see any wound care orders for {Resident #4's name} left arm." During an interview on 1/29/2026 at 12:52 PM Medical Doctor #4 stated, "No one had brought to my attention {Resident #4's name} had a skin tear in his left forearm." 3) During an observation on 1/26/2026 at 10:24 AM Resident #40 had a wound dressing to the left forearm dated 1/25/2026 with staff initials. During an observation on 1/27/2026 at 10:40 AM Resident #40 had a wound dressing dated 1/25/2026 to the left arm. [Photographic evidence obtained] Review of Resident #40's physician orders did not contain an order for wound care for the resident's left arm. During an interview on 1/27/2026 at 3:50 PM Staff D, LPN (Licensed Practical Nurse) stated, "I did not pay attention to the date on the dressing. I did see that the dressing looked old. I checked; there are no dressing change orders." During an interview on 1/27/2026 at 4:00 PM the

N0201 Continued from page 6 practice. The measures the facility will take or systems the facility will alter to ensure that the problem will be corrected and will not recur. Community wound care nurse was re-educated by community Director of Nursing on community Hand Hygiene policy, community clean to dirty workflow, establishing clean field for prior to dressing change, and community NPWT dressing change procedure. Return demonstration of hand hygiene and clean to dirty workflow competency completed to verify associate competency and understanding of required processes. Current licensed associates will be re-educated by the Director of Nursing or designee before 2/28/2026 or prior to working next scheduled shift on community Hand Hygiene policy and Dressing Change procedure with emphasis on establishing clean field and clean to dirty workflow. Education will require a return demonstration in selected areas to verify associate competency. Routine weekly hand-washing, wound dressing change surveillance rounds will be completed by community Infection Preventionist on 3 randomly selected residents for 6 weeks then monthly for 3 months. If discrepancies are identified, immediate correction action will be taken and one on one education provided when indicated. Quality Assurance Plans to monitor facility compliance to make sure that corrections are achieved and permanent. Monthly review of completed surveillance rounds results and trends will be completed by the community Infection Preventionist or designee and reported to the facility's QAPI committee for the next 3 months and then re-evaluated to determine if further monitoring is indicated. Florida Department of Health PRINTED: 04/07/2026 FREEDOM POINTE HEALTH CENTER 1460 EL CAMINO REAL DRIVE, THE VILLAGES, Florida, 32159 APPROPRIATE DEFICIENCY)

N0201 Continued from page 7 Director of Nursing stated, "Typically, we complete a risk and incident report. The nurse would do a skin assessment, let the wound care nurse know and put in orders in the system, making sure the wound care nurse sees it to make sure that no other treatment is required. The dressings should be dated. The incident report has a check list and notifying the doctor is part of it and depending on the circumstances family is also notified." SS = D N0201 During an interview on 1/29/2026 at 12:15 PM Medical Doctor #3 stated, "I have not been informed of a skin tear to the left arm of [Resident #40's name]. There should be orders for wound care and treatment provided. The nurse should write a progress note documenting the notification." Review of the facility policy and procedure titled "Care of Skin Tears-Abrasion and Minor Breaks" with a last review date of 9/23/2025 read, "Purpose: The purpose of this procedure is to guide the prevention and treatment of abrasions, skin tears, and minor breaks in the skin. Preparation. 1. Obtain a physician's order as needed. Document physician notification in medical record. Steps in the Procedure:18. Apply the ordered dressing and secure with tape or border dressing per order. (Note: Use non-allergenic tape as indicated.) Label with date and initials to top of dressing." 4) Review of Resident #15's physician order dated 1/9/2026 read, "Cleanse: NPWT [Negative Pressure Wound Therapy] to Left Axilla @ 125 mmhg [at 125 millimeters of mercury] pressure. Remove dressing, cleanse wound with Dakins. Apply skin prep to peri-wound area. Drape drape to peri-wound area. Fill wound space with black foam. Cover with drape. Do not apply foam directly to skin without drape barrier. Change dressing 3x [times] weekly, every day shift every Mon [Monday], Wed [Wednesday], Fri [Friday] AND as needed for compromised drg [dressing] seal." During an observation on 1/29/2026 at 11:45 AM the Wound Care Nurse performed hand hygiene, don a gown and two sets of gloves. The Wound Care Nurse entered Resident #15's room and placed the wound care supplies on top of Resident #15's cabinet without placing a barrier underneath. The Wound Care Nurse proceeded to clean Resident #15's bedside table, throwing away a water cup in the garbage, placing a newspaper on top of the resident's recliner, sanitized the bedside table, and placed the wound care supplies on the table. The Wound Care Nurse removed the top pair of gloves leaving the first original pair of gloves on, did not

N0201 SS = D Continued from page 8 perform hand hygiene, put a new pair of gloves on, on top of the first original gloves. The Wound Care nurse removed the dressing from Resident #15's left arm, removed the top pair of gloves leaving the first original gloves on, did not perform hand hygiene, and put another pair of gloves on. The Wound Care Nurse cleansed the wound, pat dried the wound, removed the top pair gloves leaving the original pair of gloves on, did not perform hand hygiene, and put another pair of gloves on. The Wound Care Nurse applied a drape to the peri wound area, filled the wound with a black foam covering with a transparent drape, removed the wound with a black foam covering with a transparent drape, removed the top pair of gloves leaving the original pair on, did not perform hand hygiene, put a new set of gloves on, cut a hole in the barrier and placed tubing with an adhesive pad over the wound. The wound care nurse proceeded to look for a new disposable canister for the wound vacuum system. One was not located in the resident's room. The Wound Care Nurse removed both sets of gloves, performed hand hygiene, and exited the room. The Wound Care Nurse returned to the room, performed hand hygiene, put two sets of gloves on, connected the canister tubing, and initiated the negative pressure on the pump for the wound vacuum as ordered. The wound care nurse dated the wound dressing, removed both sets of gloves, and performed hand hygiene. During an interview on 1/29/2026 at 12:15 PM the Wound Care Nurse stated, "I should have performed hand hygiene when I took my gloves off." During an interview on 1/28/2026 at 1:00 PM the Director of Nursing stated, "Staff should wash their hands in between each wound care step. The staff should take their gloves off and wash their hands and put a new pair of gloves on." During an interview on 1/28/2026 at 3:54 PM the Infection Preventionists stated, "I would expect the staff to perform hand hygiene. I don't know why they are putting two sets of gloves on. They would need to remove both sets of gloves and put new gloves back on after washing their hands." Review of the facility policy and procedure titled "Handwashing/Hand Hygiene" with a last review date of 9/23/2025 read, "9. The use of gloves does not replace hand washing/hand hygiene." Review of the facility policy and procedure titled "Negative Pressure Wound Therapy" with a last review date of 9/23/2025 read, "Steps in the procedure: 1. Identify and size the wound to be treated. 2. Wash hands and apply gloves. 3 Clean wound according to" N0201 Florida Department of Health PRINTED: 04/07/2026 FREEDOM POINTE HEALTH CENTER 1460 EL CAMINO REAL DRIVE, THE VILLAGES, Florida, 32159 APPROPRIATE DEFICIENCY)

N0201 Continued from page 9 N0201 SS = D facility protocol, or as ordered. 4. Remove gloves. 5. Wash Hands and apply clean gloves. 6. Cut sponge dressing to size." Class III 106083 01/29/2026 FREEDOM POINTE HEALTH CENTER 1460 EL CAMINO REAL DRIVE, THE VILLAGES, Florida, 32159 PREFIX TAG ID PREFIX TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETION DATE

F0000 INITIAL COMMENTS

F0000 02/05/2026 An unannounced recertification survey was conducted on January 26, 2026, through January 29, 2026, at Freedom Pointe Health Center. The facility was not in compliance with Code of Federal Regulations (CFR) 42, Part 483, Requirements for Long Term Care Facilities.

F0684 SS = D Quality of Care

F0684 Facility Response 02/28/2026 CFR(s): 483.25 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. This REQUIREMENT is NOT MET as evidenced by: Based on observation, interview, and record review the facility failed to ensure wound care and treatment was provided according to professional standards for 3 of 6 residents. Residents #4, #15, and #40, reviewed for skin conditions. Findings include: 1) During an observation on 1/26/2026 at 9:45 AM Resident #15 had a wound gauze dressing wrapped to the left upper arm that was not dated. During an interview on 1/26/2026 at 9:45 AM Resident #15 stated, "The wound vac (vacuum, used to treat wounds) is not connected because when they were going to change it, they realized they did not have supplies for the suction." Review of Resident #15's physician order dated 1/9/2026 read, "Cleanse: NPWT [Negative Pressure Wound Therapy] to Left Axilla @ 125 mmhg at 125 milliliters to mercury pressure. Remove dressing, cleanse wound with Dakins, apply skin prep to peri-wound area, apply drape This plan of correction for the above reference facility is in response to the Statement of Deficiencies. While this document is being submitted as confirmation of the facility's on-going efforts to comply with all statutory and regulatory requirements, it should not be construed as an admission or agreement with the findings and document outlines specific actions in response to the identified issues. We have not provided a detailed response to each allegation or findings, nor have we identified mitigating factors.

F 684 Quality of Care Corrective action for residents noted to have been affected by the deficient practice. Resident #15 re-evaluation of resident current wound status was completed by DON 1/26/2026. No adverse effects noted. Wound vac was changed per physician orders using appropriate infection control procedure by RN on 1/26/2026. ARNP notified of identified discrepancy with completion of routine dressing change. Resident #15 care plan was reviewed and updated as indicated. Resident #4 current wound was re-evaluated by DON 1/26/2026. No adverse effect noted from evaluation. Findings were documented in resident's electronic medical record. Physician notified of findings by RN on 1/26/2026. New orders 106083 01/29/2026 FREEDOM POINTE HEALTH CENTER 1460 EL CAMINO REAL DRIVE, THE VILLAGES, Florida, 32159 PREFIX TAG ID PREFIX TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETION DATE

F0684 SS = D Continued from page 1 to peri-wound area. Fill wound space with black foam, cover with drape. Do not apply foam directly to skin without drape barrier. Change dressing 3x [times] weekly, every day shift every Mon (Monday), Wed (Wednesday), Fri (Friday) and as needed for compromised drg (dressing) seal. Monitor NPWT to left axilla and canister. Notify MD (Medical Doctor) for s/s (signs/symptoms) of bleeding. If dressing is unable to maintain pressure, check for leakage and reinforce. If problem persists, remove and change entire dressing. When machine malfunctions and unable to fix it, remove granufloam, pack loosely with moist gauze, secure with secondary dressing and notter wound every shi* Do not leave granufloam longer than 2 hours without a well functioning wound vac machine.* Review of Resident #15's Treatment Administration Record for the month of January 2026 read, "Cleanse NPWT to left Axilla." Documented on 1/23/2026 the order was coded with a "9" [other/see nurse notes]. Review of Resident #15's progress noted dated 1/23/2026 read, "Awaiting Supplies." During an interview on 1/27/2026 at 3:45 PM Staff A, Licensed Practical Nurse (LPN) stated, "We had to change the dressing, and we needed the suction and there were no supplies for the wound vac. The wound nurse is responsible for ordering supplies for the vacuum. I went to look and the wound care nurse was on vacation, and I went to his office. I notified both Unit Managers that we did not have the supplies. I went to Resident #15 [dressing. My Unit Manager told me to remove the dressing and wait for the supplies. The dressing was intact, that is why we did not remove it and the vacuum was working properly. We left the vacuum connected with the suction. [Staff B Registered Nurse's name] is the Unit Manager. The resident agreed to leave the dressing in as because if I remove it, we would not be able to put the vacuum back on and it would be a regular dressing. I don't know if she [Staff B] notified the provider." During an interview on 1/27/2026 at 4:00 PM the Director of Nursing (DON) stated, "I was not aware of [wound vac dressing that was not changed due to not having supplies]. The wound care nurse is on vacation. It is not likely they did not have supplies, not normal here. Typically, the staff would have let me know. I need to look into what happened." During an interview on 1/28/2026 at 7:48 AM the DON stated, "Supplies were here in the overflow storage, and the nurse was not sure where the supplies were

F0684 Continued from page 1 received per physician and implemented on 1/26/2026. Care plan reviewed and updated as indicated. Resident #40 current wound was re-evaluated by DON on 1/27/2026. No adverse effect noted from evaluation. Findings were documented in resident's electronic medical record. Physician notified of findings by LPN on 1/27/26. New orders received per physician and implemented on 1/27/2026. Care plan reviewed and updated as indicated. How will the facility identify other residents having the potential to be affected by the same deficient practice? Residents currently residing in the community have the potential to be affected by the alleged practice. Community wide skin sweep completed by community clinical interdisciplinary team on 1/27/2026. No further residents identified as being affected. The measures the facility will take or systems the facility will alter to ensure that the problem will be corrected and will not reoccur. Current licensed clinical associates will be re-educated by the Director of nursing or designee on or before 2/28/2026 or prior to work next scheduled shift on community process for timely implementation of physician orders, required wound care documentation, physician notification, and event reporting and on community Skin Tear policy and Negative Pressure Wound Therapy policy. Residents identified as being admitted or having a newly acquired alteration in skin integrity will be reviewed during routine clinical meeting by the clinical interdisciplinary team to validate completion of required physician notification, order transcription, and assessment documentation. If discrepancies are identified, immediate corrective action will be taken and one on one education provided when indicated. 106083 01/29/2026 FREEDOM POINTE HEALTH CENTER 1460 EL CAMINO REAL DRIVE, THE VILLAGES, Florida, 32159 PREFIX TAG ID PREFIX TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETION DATE

F0684 SS = D Continued from page 2 located. I would expect them to notify the provider.* During an interview on 1/29/2026 at 9:50 AM Staff B, RN (Registered Nurse) Unit Manager, stated, "We were going to change (Resident #155's name) wound vac dressing and we did not have supplies to do the dressing change. We went to the supply room and were unable to locate the supplies. I did not call the provider, the 3-11 supervisor was aware, and we spoke to the resident, and she was okay with leaving the dressing how it was. It was functioning correctly at that time. The supervisor was going to follow up after that time." During an interview on 1/29/2026 at 10:07 AM Medical Doctor #1 stated, "I did not know about the wound vac. If it closed did not have supplies, they would need to keep it closed until they have supplies again. I was not aware of it." During an interview on 1/29/2026 at 10:17 AM the Advance Practice Registered Nurse (APRN #1) stated, "The staff called me and I gave instructions to change the dressing to Friday evening [01/23/2026] to a wet to dry dressing." During an interview on 1/29/2026 at 12:14 PM the DON stated, "The staff did not change the dressing on Friday [1/23/2026]. The dressing was changed on Saturday [1/24/2026] because the suctioning was malfunctioning and the staff changed the dressing to moist dressing. They should have called me and double checked for the supplies. The supplies were available but in the overflow storage. If the staff were unable to change the dressing they should have contacted the provider. The night shift nurse did not contact the provider on Friday [1/23/2026]. The dressing should also have been dated when it was changed on 1/24/2026." Review of the facility policy and procedure titled "Negative Pressure Wound Therapy" with a last review date of 9/23/2025 read, "Purpose: The purpose of this procedure is to provide guidelines for establishing and maintain negative pressure wound therapy (NPWT). General Guidelines: 3. Change dressings per physician orders and manufacturer guidelines." 2) During an observation on 1/26/2026 at 11:00 AM Resident #4 had a wound dressing to the left forearm. The wound dressing was not dated. [Photographic evidence obtained] During an interview on 1/26/2026 at 11:00 AM Resident #4 stated, "This happened [dressing on left forearm] while I was in the exercise room and it [the wound

F0684 Continued from page 2 During weekly risk review meetings, the interdisciplinary team will review the clinical record of residents with new skin events. The review will be documented in the resident's medical record. Routine weekly review will be completed by Director of Nursing for 5 randomly selected residents identified with skin alterations requiring dressing changes or NPWT to verify completion of physician ordered treatment for six weeks and then monthly for 3 months. Quality Assurance Plans to monitor facility compliance to make sure that corrections are achieved and permanent. Monthly review of completed routine audit results and trends will be completed by the Director of Nursing or designee and reported to the facility's QAPI committee for the next 3 months and then re-evaluated to determine if further monitoring is indicated. 01/29/2026 FREEDOM POINTE HEALTH CENTER 1460 EL CAMINO REAL DRIVE, THE VILLAGES, Florida, 32159 [X4] ID PREFIX TAG ID PREFIX TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) [X5] COMPLETION DATE

F0684 SS = D Continued from page 3 dressing has not been changed in about a week.* Review of Resident #4's physician orders did not document a wound care order for the resident's left forearm. Review of Resident #4's medical record, the record did not contain documentation of the resident having suffered an injury resulting in a wound to the left forearm. During an observation on 1/27/2026 at 3:55 PM Staff C, RN of Resident #4, the resident was lying in bed and to his left arm there was a dressing dated 1/26/2026. Staff C peeled off the left corner of the dressing and there was a skin tear. Staff C placed the dressing back on Resident #4's arm. During an interview on 1/27/2026 at 4:00 PM Staff C, RN stated, "I do not see any wound care orders for [Resident #4's name] left arm." During an interview on 1/29/2026 at 12:52 PM Medical Doctor #2 stated, "No one had brought to my attention [Resident #4's name] had a skin tear in his left forearm." 3) During an observation on 1/26/2026 at 10:24 AM Resident #40 had a wound dressing to the left forearm dated 1/25/2026 with staff initials. During an observation on 1/27/2025 at 10:40 AM Resident #40 had a wound dressing dated 1/25/2026 to the left arm. [Photographic evidence obtained] Review of Resident #40's physician orders did not contain an order for wound care for the resident's left arm. During an interview on 1/27/2026 at 3:50 PM Staff D, LPN (Licensed Practical Nurse) stated, "I did not pay attention to the date on the dressing. I did see that the dressing looked old. I checked; there are no dressing change orders." During an interview on 1/27/2026 at 4:00 PM the Director of Nursing stated, "Typically, we complete a risk and incident report. The nurse would do a skin assessment, let the wound nurse know and put in orders in the system; making sure the wound care nurse sees it to make sure that no other treatment is required. The dressings should be dated. The incident report has a check list and notifying the doctor is part of it and depending on the circumstances family is 01/29/2026 FREEDOM POINTE HEALTH CENTER 1460 EL CAMINO REAL DRIVE, THE VILLAGES, Florida, 32159 TAG CROSS-REFERENCED TO THE COMPLETION DATE

F0684 Continued from page 4 SS = D also notified. F0684 During an interview on 1/29/2026 at 12:15 PM Medical Doctor #3 stated, "I have not been informed of a skin tear to the left arm of (Resident #40's name). There should be orders for wound care and treatment provided. The nurse should write a progress note documenting the notification." Review of the facility policy and procedure titled "Care of Skin Tears-Abrasion and Minor Breaks" with a last review date of 9/23/2025 read, "Purpose: The purpose of this procedure is to guide the prevention and treatment of abrasions, skin tears, and minor breaks in the skin. Preparation. 1. Obtain a physician's order as needed. Document physician notification in medical record. Steps in the Procedure:18. Apply the ordered dressing and secure with tape or border dressing per order. (Note: Use non-allergic tape as indicated.) Label with date and initials on top of dressing."

F0757 Drug Regimen is Free from Unnecessary Drugs F0757 Facility Response SS = D 02/28/2026 CFR(s): 483.45(d)(1)-(6) $483.45(d) Unnecessary Drugs-General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used- $483.45(d)(1) In excessive dose (including duplicate drug therapy); or $483.45(d)(2) For excessive duration; or $483.45(d)(3) Without adequate monitoring; or $483.45(d)(4) Without adequate indications for its use; or $483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or $483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. This plan of correction for the above reference facility is in response to the Statement of Deficiencies. While this document is being submitted as confirmation of the facilities on-going efforts to comply with all statutory and regulatory requirements, it should not be construed as an admission or agreement with the findings and document outlines specific actions in response to the identified issues. We have not provided a detailed response to each allegation or findings, nor have we identified mitigating factors.

F757 Drug Regimen is Free from Unnecessary Medication Corrective action for residents noted to have been affected by the deficient practice. Resident #61 culture and sensitivity lab results review completed by community Director of Nursing on 1/27/26. ARNP was notified of findings of culture and sensitivity. New orders received and reflected in the resident's medical record. The residents' care plan was reviewed by the community interdisciplinary team and updated as indicated. 01/29/2026 FREEDOM POINTE HEALTH CENTER 1460 EL CAMINO REAL DRIVE, THE VILLAGES, Florida, 32159 TAG CROSS-REFERENCED TO THE COMPLETION DATE

F0757 Continued from page 5 F0757 Continued from page 5 SS = D This REQUIREMENT is NOT MET as evidenced by: Based on interview and record review the facility failed to ensure antibiotic medications were administered based on culture and sensitivity results for 1 of 6 residents, Resident #61, reviewed for medication management. Findings include: Review of Resident #61's physician order dated 1/21/2026 read, "Cipro Oral Tablet 500 MG (milligram) (Ciprofloxacin HCl) [Hydrochloride] give 1 tablet by mouth two times a day for E. Coli UTI (Escherichia coli urinary tract infection) for 7 Days." Review of Resident #61's Medication Administration Record (MAR) for the month of January 2020 documented Cipro 500 mg was administered from 1/21/2026 to 1/27/2026. Review of Resident #61's Urine Culture [a lab test that will identify the bacteria causing the infection] with a reported date of 1/21/2026 read, "Results: Escherichia coli (Isolate 1). Sensitivity Analysis. Ciprofloxacin R [Resistant/Ineffective]." Review of Resident #61's physician follow up note dated 1/21/2026 read, "Patient observed during am with physical therapy and doing well. Reviewed urine culture and sensitivity. Will have to discontinue Bactrim and change patient to cipro per sensitivity report. Patient otherwise doing well." During an interview on 1/28/2026 at 7:56 PM the Director of Nursing stated, "I reviewed the culture and sensitivity and Cipro was resistant. There was a note in the system that stated the antibiotic was changed to cipro due to the sensitivity. Normally the results will come in and the Infection Preventionist will review the antibiotic and the sensitivity. The expectation and normal process is to make sure that the antibiotics prescribed are correct." During an interview on 1/28/2026 at 3:54 PM the Infection Preventionist stated, "I don't remember that one [Resident #61's culture and sensitivity]. When I looked at the antibiotic time out it was the same day that the provider had changed it [the antibiotic] to cipro and I thought she had looked at it [the culture and sensitivity]. I understand now that I am to look at the culture to see if the antibiotic the provider changes it to is susceptible or not and notify the How will the facility identify other residents having the potential to be affected by the same deficient practice? Residents currently residing in the community requiring the use of antibiotic therapy have the potential to be affected by the identified interdisciplinary team on 1/27/2026. No further residents identified as being affected. The measures the facility will take or systems the facility will alter to ensure that the problem will be corrected and will not reoccur. Current associates will be re-educated by the Director of Nursing or designee before 2/28/2026 or prior to working next scheduled shift on community process of physician notification of identified culture results and/or order discrepancies, and community Antibiotic Stewardship policy. Residents with new physician orders for antibiotic therapy will be reviewed by routine clinical meeting by community clinical interdisciplinary team to validate review of completed culture results when indicated and appropriate usage of antibiotics ordered. If discrepancies are identified, immediate physician notification and review will be completed for clarification of current antibiotic usage. During weekly risk review meetings, the interdisciplinary team will review the clinical record of residents requiring new antibiotic usage to review antibiotic effectiveness and completion. The review will be documented in the resident medical record. Routine weekly review will be completed by Infection Preventionist on current residents requiring new antibiotic therapy to validate usage is appropriate upon sensitivity lab results when applicable. Routine weekly review will be completed for 6 weeks and then monthly for 3 months. FREEDOM POINTE HEALTH CENTER 1460 EL CAMINO REAL DRIVE, THE VILLAGES, Florida, 32159

F0757 SS = D Continued from page 6 provider.

F0757 Continued from page 6 Quality Assurance Plans to monitor facility compliance to make sure that corrections are achieved and permanent. During an interview on 1/29/2026 at 11:41 AM APRN #2 stated, "The preliminary results showed E. Coli and I started her on Cipro. I have been notified that the antibiotic was resistive and had to be changed." Review of the facility policy and procedure titled "Antibiotic Stewardship" with a last review date of 9/23/2025 read, "Policy Statement. Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. Policy interpretation and implementation: 11. When culture and sensitivity (C&S) is ordered lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued."

F0812 SS = D Food Procurement, Store/Prepare/Serve-Sanitary

F0812 F-Tag: F812 – Food Procurement, Store/Prepare/Serve – Sanitary Conditions (Hot Food Holding Temperatures) 02/28/2026 CFR(s): 483.60(1)(2) $483.60(i) Food safety requirements. The facility must - $483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. $483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT IS NOT MET as evidenced by: Based on observation, interview, and policy and procedure review the facility failed to ensure hot food items were maintained at the proper temperatures during 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? At the time of observation, the food items (bacon, sausage patties, and hashbrowns) were identified as being below the required hot holding temperature while on the steam table and had not been served to residents and did not leave dietary control. The food was immediately discarded and replacement food was prepared. The replacement items were reheated to at least 165°F and held above 140°F prior to service. The Assistant Dietary Director and dietary staff present were re-educated regarding required hot holding temperatures and the expectation to verify temperatures prior to the start of meal service on 01/28/2026. 2. How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken: Because meal preparation and service processes occur throughout the facility, residents had the potential to be affected. The facility reviewed meal service practices across dining areas and meal periods. Temperature monitoring procedures were reinforced and temperature verification 01/29/2026 FREEDOM POINTE HEALTH CENTER 1460 EL CAMINO REAL DRIVE, THE VILLAGES, Florida, 32159 CROSS-REFERENCED TO THE COMPLETION DATE

F0812 Continued from page 7 SS = D meal service. Findings include: During an observation on 01/27/26 at 7:32 AM of the breakfast service on the West Wing, the Assistant Dietary Director was beginning to serve the breakfast meal. A review of the temperatures for the bacon, sausage patties, and hashbrowns were 117 to 118 degrees Fahrenheit (F) on the steam table. During an interview on 01/27/26 at approximately 7:33 AM the Assistant Dietary Director verified the temperatures of the bacon, sausage patties, and hashbrowns. During an interview on 1/27/26 at approximately 8:00 AM the Dietary Director stated, "The temperatures of 117 and 118 for hot food items are within the danger zone area." Review of the policy and procedure titled, "Temperatures and Safe Food Handling" last reviewed on 09/23/26 read, "Objective: Participants will be able to understand the importance of proper temperatures and food handling procedures when handling food for residents. 2. e. Failure to reheat to 165 F or hold food at appropriate temperatures-cold food less than or equal to 41 F and hot foods more than or equal to 140 F."

F0812 Continued from page 7 checks were performed during subsequent meal services to confirm foods were held at appropriate temperatures prior to service. Dietary staff received re-education and competency verification on proper food temperature monitoring and safe food handling practices as indicated on 01/28/2026. 3. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: The facility implemented the following systemic changes: Dietary staff were re-educated on the facility food safety policy requiring hot foods to be maintained at ≥140°F and reheated foods to reach ≥165°F prior to service. A pre-service temperature verification process for temperatures to be taken and documented before food leaves the kitchen and again before tray line or dining service begins. Supervisory dietary staff or designee will review and sign off on temperature logs prior to meal service. Thermometers were checked for proper function and calibrated as needed. Staff were instructed to pre-heat steam tables prior to placing food items onto the serving line. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur (Quality Assurance Program): The facility will monitor compliance through its Quality Assurance and Performance Improvement (QAPI) program. Food temperatures will be checked and documented five (5) times per week for four (4) weeks, then three (3) times per week for four (4) weeks, followed by one (1) time per week for four (4) weeks. Any food temperatures identified outside the safe range will be immediately addressed and corrective actions 106083 01/29/2026 FREEDOM POINTE HEALTH CENTER 1460 EL CAMINO REAL DRIVE, THE VILLAGES, Florida, 32159 PREFIX TAG ID PREFIX TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETION DATE

F0812 SS = D

F0812 Continued from page 8 will be documented. Monitoring results will be reviewed and discussed during QAPI meetings.

F0842 SS = D Resident Records - Identifiable Information CFR(s): 483.20(f)(5),483.70(h)(1)-(5) $483.20(f)(5) Resident-Identifiable information. (i) A facility may not release the information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. $483.70(h) Medical records. $483.70(h)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are- (i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized $483.70(h)(2) The facility must keep confidential all information contained in the resident's records, regardless of the form or release method of the records, except from release is- (i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings,

F0842 Facility Response This plan of correction for the above reference facility is in response to the Statement of Deficiencies. While this document is being submitted as confirmation of the facilities on-going efforts to comply with all statutory and regulatory requirements, it should not be construed as an admission or agreement with the findings and document outlines specific actions in response to the identified issues. We have not provided a detailed response to each allegation or findings, nor have we identified mitigating factors.

F0842 Resident Record – Identifiable Information Corrective action for residents noted to have been affected by the deficient practice. Resident #5 medication administration records reviewed by DON on 1/27/2026. Physician notified by RN on 1/27/2026 of administration discrepancy. New administration parameter orders were received and implemented. Resident medical records were updated to reflect order updates and physician notification. Care plan reviewed and updated as indicated. Physician completed medication regimen review for appropriateness and safety on 1/27/2026. Resident #15 pain medication administration records reviewed by DON on 1/27/2026. Physician was notified by RN on 1/27/2026 of administration outside of prescribed parameters. New administration parameters obtained, and documentation of orders and physician notification were completed in resident records. The resident care plan was reviewed and updated as indicated. Physician completed medication regimen review for appropriateness and safety on 1/27/2026. How will the facility identify other residents having the potential to be affected by the same deficient 02/28/2026 106083 01/29/2026 FREEDOM POINTE HEALTH CENTER 1460 EL CAMINO REAL DRIVE, THE VILLAGES, Florida, 32159 PREFIX TAG ID PREFIX TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETION DATE

F0842 SS = D Continued from page 9 law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512. $483.70(h)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use. $483.70(h)(4) Medical records must be retained for- (i) The period of time required by State law; or (ii) Five years from the date of discharge when there is no requirement in State law, or (iii) For a minor, 3 years after a resident reaches legal age under State law. $483.70(h)(5) The medical record must contain- (i) Sufficient information to identify the resident; (ii) A record of the resident's assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician's, nurses', and other licensed professional's progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under $483.50. This REQUIREMENT IS NOT MET as evidenced by: Based on interview and record review the facility failed to ensure residents' records were complete and accurate for documentation of provider notification when physician orders were not followed as prescribed for 2 of 6 residents, Residents #5 and #15, reviewed for medication management. Findings include:

F0842 Continued from page 9 practice? Residents requiring the use of PRN medication, administration parameters, and/or medication holding instructions have the potential to be affected by the identified practice. Community review completed by community interdisciplinary team on 1/27/2026. Physician notified of residents requiring clarification of medication administration and/or hold parameter orders. Orders obtained and documented in resident's medical record. Care plans for identified residents were reviewed and updated as indicated. The measures the facility will take or systems the facility will alter to ensure that the problem will be corrected and will not reoccur. Current licensed clinical associates will be re-educated by the community Director of Nursing or designee before 2/28/2026 or prior to working next scheduled shift on community Medication Administration policy, Charting and Documentation policy, community process of follow physician orders, and community process for physician notification of omitted medication administration. New physician orders are routinely reviewed during morning clinical meetings by the interdisciplinary team to validate completion of transcription or need of clarification of parameters. If discrepancies are identified, immediate physician notification completed and one on one education provided when indicated. Missed and Held medication reports routinely reviewed during morning clinical meeting my interdisciplinary team to verify medication administration parameters are being followed and required physician notification completed. If discrepancies are identified, immediate corrective action is completed and one on one education provided when indicated. Monthly medication order reviews will be completed by community Consultant Pharmacist for identification of order discrepancies. Results of routine reviews will be provided reviewed by the community Director of Nursing. FREEDOM POINTE HEALTH CENTER 1460 EL CAMINO REAL DRIVE, THE VILLAGES, Florida, 32159 CROSS-REFERENCED TO THE DATE

F0842 SS = D Continued from page 10 1) Review of Resident #5's physician order dated 12/15/2025 read, "Carvedilol Oral Tablet 12.5 MG (Milligram) (Carvedilol) Give 1 tablet by mouth two times a day for HTN (Hypertension)." Review of Resident #5's Medication Administration Record (MAR) for the month of January 2026 for Carvedilol 12.5 MG documented on 1/17/2026 at 1700 (5:00PM) blood pressure 119/58, Pulse 84, coded "4" (vital signs outside of parameters), dated 1/17/2026 at 1700 no blood pressure or pulse was documented, coded "5" (Hold/See Nurse Note), dated 1/18/2026 at 1700 blood pressure 109/52, Pulse 84, coded "4" (vital signs outside of parameters), dated 1/24/2026 at 0900 (9:00AM) no blood pressure or pulse documented, coded "4" and at 1700 blood pressure or pulse documented, coded "4" and at 1700 blood pressure 104/57, pulse 82, coded "4" and dated 1/25/2026 at 0900 no blood pressure or pulse documented, coded "4". Review of Resident #5's progress note dated 1/17/2026 read, "Held Carvedilol, BP [Blood Pressure] 108/50." Review of Resident #5's progress note dated 1/18/2026 did not contain documentation related to the resident's Carvedilol not being administered. Review of Resident #5's progress notes for the period of 01/10/2026 through 01/25/2026 did not contain documentation the physician was notified the resident's Carvedilol was not administered. During an interview on 1/28/2026 at 7:52 AM the Director of Nursing (DON) stated, "I would expect nursing staff if they were going to hold a medication that does not have parameters and they have spoken to the provider they should document it in the record that they spoke to the provider." During an interview on 1/28/2026 at 1:59 PM Staff E Licensed Practical Nurse (LPN) stated, "If the resident's blood pressure is low, I will hold the medication and notify the provider. I should have documented in the progress notes that I contacted the provider, but I do not think I did." During an interview on 1/28/2026 at 5:00PM with Staff F, LPN, stated, "Sometimes [Resident #5's name] representative will not want the medication to be administered and if the blood pressure is low, I will hold the medication. I will always contact her [Resident #5's] provider to let him know. I do not think I documented the notification in the system." During an interview on 1/29/2026 at 10:43 AM Medical F0842 Continued from page 10 Routine weekly reviews will be completed by the Director of Nursing on medication administration specific to orders with administration parameters for 5 randomly selected residents for 6 weeks and then monthly for 3 months. Quality Assurance Plans to monitor facility compliance to make sure that corrections are achieved and permanent. Monthly review of completed physician order reviews, Missed/Held administration reports and monthly Consultant Pharmacist review results and trends will be reported to the Director of Nursing or designee and 3 months and then re-evaluated to determine if further monitoring is indicated. 01/29/2026 1460 EL CAMINO REAL DRIVE, THE VILLAGES, Florida, 32159 PREFIX TAG CROSS-REFERENCED TO THE COMPLETION DATE

F0842 Continued from page 11 SS = D Doctor #4 stated, "The staff call me to notify when they are going to hold [Resident #5's name] medication." 2) Review of Resident #15's physician order dated 1/8/2026 read, "Oxycodone HCl Oral Tablet 5 MG [Milligram] give 1 tablet by mouth every 8 hours as needed for Acute Pain (7-10)." Review of Resident #15's MAR for the month of January 2026 documented Oxycodone 5 mg was administered on 1/6/2026 at 1248 [12:48 PM] pain level 6, dated 1/7/2026 at 1757 [5:57PM] pain level 6, dated 1/10/2026 at 2110 [9:10 PM] pain level 6, dated 1/20/2026 at 0652 [6:52 AM] pain level 5, dated 1/24/2026 at 1929 [7:29 PM] pain level 2, dated 1/25/2026 at 1236 [12:36 PM] pain level 4, and dated 2117 [9:17 PM] pain level 4. Review of Resident #15's progress notes did not contain documentation of provider notification regarding oxycodone being administered when the pain level was below the physician ordered parameters. During an interview on 1/27/2026 at 3:45 PM Staff A, LPN, stated, "I was giving her oxycodone before her wound care changes. She [Resident #15] likes to take that medication to handle the pain. The doctor is aware that this is the resident's preference." During an interview on 1/28/2026 at 7:48AM the Director of Nursing stated, "If the medication is outside parameters the staff need to speak to the provider and write a note and document they spoke to the provider." During an interview on 1/28/2026 at 1:59 PM Staff E, LPN, stated, "I cannot recall , but I normally will not hold a medication that does not have parameters without contacting the provider." During an interview on 1/28/2026 at 5:00 PM Staff F, LPN, stated, "I am new and still learning the system. I think I wrote the pain level wrong in that section." During an interview on 1/29/2026 at 10:17AM APRN # 1 stated, "The staff call me about Resident #15's pain medication and request from the patient." Review of the facility policy and procedure titled "Administering Medications" with a last review date of 9/23/2025 read, "Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation. 4. Medication are administered in accordance with 01/29/2026 FREEDOM POINTE HEALTH CENTER 1460 EL CAMINO REAL DRIVE, THE VILLAGES, Florida, 32159 TAG CROSS-REFERENCED TO THE COMPLETION DATE

F0842 Continued from page 12 SS = D prescriber orders, including any required time frame." Review of the facility policy and procedure titled "Charting and Documentation" with a last review date of 9/23/2025 read, "Policy Statement: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Policy Interpretation and Implementation. 3. Documentation in the medical record be objective (not opinionated or speculative), complete, and accurate."

F0880 Infection Prevention & Control SS = D CFR(s): §483.80(a)(1)(2)(4)(e)(f) §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals based upon the facility assessment conducted according to §483.71 and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility;

F0842

F0880 Facility Response 02/28/2026 This plan of correction for the above reference facility is in response to the Statement of Deficiencies. While this document is being submitted as confirmation of the facility's on-going efforts to comply with all statutory and regulatory requirements, it should not be construed as an admission or agreement with the findings and document outlines specific actions in response to the identified issues. We have not provided a detailed response to each allegation or findings, nor have we identified mitigating factors.

F880 Infection Control Corrective action for residents noted to have been affected by the deficient practice. Resident #15 re-evaluation of resident current wound status was completed by DON 1/29/2026. No adverse effects noted. Wound vac was changed per physician orders using appropriate infection control procedure by RN on 1/29/2026. Physician notified. How will the facility identify other residents having the potential to be affected by the same deficient practice? Residents currently residing in the community requiring wound care and dressing changes 01/29/2026 FREEDOM POINTE HEALTH CENTER 1460 EL CAMINO REAL DRIVE, THE VILLAGES, Florida, 32159 APPROPRIATE DEFICIENCY) COMPLETION DATE

F0880 Continued from page 13 F0880 Continued from page 13 SS = D (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food; if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. $483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. $483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. $483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT IS NOT MET as evidenced by: Based on observation, interview, and record review the facility failed to prevent the possible spread of infection when not performing hand hygiene during wound care for 1 of 6 residents. Resident #15, reviewed for skin conditions. Findings include: have the potential to be affected by the identified practice. Community review completed by community interdisciplinary team on 1/29/2026. No further residents identified as being affected by the cited practice. The measures the facility will take or systems the facility will alter to ensure that the problem will be corrected and will not recur. Community wound care nurse was re-educated by community Director of Nursing on community Hand Hygiene policy, community clean to dirty workflow, establishing clean field for prior to dressing change, and community NPWT dressing change procedure. Return demonstration of hand hygiene and clean to dirty workflow competency completed to verify associate competency and understanding of required processes. Current licensed associates will be re-educated by the Director of Nursing or designee before 2/28/2026 or prior to working next scheduled shift on community Hand Hygiene policy and Dressing Change procedure with emphasis on establishing clean field and clean to dirty workflow. Education will require a return demonstration in selected areas to verify associate competency. Routine weekly hand-washing, wound dressing change surveillance rounds will be completed by community Infection Preventionist on 3 randomly selected residents for 6 weeks then monthly for 3 months. If discrepancies are identified, immediate correction action will be taken and one on one education provided when indicated. Quality Assurance Plans to monitor facility compliance to make sure that corrections are achieved and permanent. Monthly review of completed surveillance rounds results and trends will be completed by the community Infection Preventionist or designee and reported to the facility's QAPI committee for the next 3 months and then re-evaluated to determine if further monitoring is indicated. 106083 01/29/2026 FREEDOM POINTE HEALTH CENTER 1460 EL CAMINO REAL DRIVE, THE VILLAGES, Florida, 32159 PREFIX TAG ID PREFIX TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETION DATE

F0880 SS = D

F0880 Continued from page 14 Review of Resident #15's physician order dated 1/9/2026 read, "Cleanse: NPWT [Negative Pressure Wound Therapy] to Left Axilla @ 125 mmHg [at 125 millimeters of mercury] pressure. Remove dressing, cleanse wound with Dakins. Apply skin prep to peri-wound area. Apply drape to peri-wound area. Fill wound space with black foam. Cover with drape. Do not apply foam directly to skin without drape barrier. Change dressing 3x [times] weekly; every day shift every Mon (Monday), Wed (Wednesday), Fri (Friday) AND as needed for compromised drg [dressing] seal." During an observation on 1/29/2026 at 11:45 AM the Wound Care Nurse performed hand hygiene, don a gown and two sets of gloves. The Wound Care Nurse entered Resident #15's room and placed the wound care supplies on top of Resident #15's cabinet without placing a barrier underneath. The Wound Care Nurse proceeded to clean Resident #15's bedside table, throwing away a water cup in the garbage, placing a newspaper on top of the resident's recliner, sanitized the bedside table, and placed the wound care supplies on the table. The Wound Care Nurse removed the top pair of gloves leaving the first original pair of gloves on, did not perform hand hygiene, put a new pair of gloves on, on top of the first original gloves. The Wound Care Nurse removed the dressing from Resident #15's left arm, removed the top pair of gloves leaving the first original gloves on, did not perform hand hygiene, and put another pair of gloves on. The Wound Care Nurse cleansed the wound, pat dried the wound, removed the top pair gloves leaving the original pair of gloves on, did not perform hand hygiene, and put another pair of gloves on. The Wound Care Nurse applied a drape to the peri wound area, filled the wound with a black foam covering with a transparent drape, removed the top pair of gloves leaving the original pair of gloves on, did not perform hand hygiene, put a new set of gloves on, cut a hole in the barrier, and placed tubing with an adhesive pad over the wound. The wound care nurse proceeded to look for a new disposable canister for the wound vacuum system. One was not located in the resident's room. The Wound Care Nurse removed both sets of gloves, performed hand hygiene, and exited the room. Wound Care Nurse returned to the room, performed hand hygiene, put two sets of gloves on, connected the canister tubing, and initiated the negative pressure on the pump for the wound vacuum as ordered. The wound care nurse dated the wound dressing, removed both sets of gloves, and performed hand hygiene. During an interview on 1/29/2026 at 12:15 PM the Wound Care Nurse stated, "I should have performed hand hygiene when I took my gloves off." 106083 01/29/2026 FREEDOM POINTE HEALTH CENTER 1460 EL CAMINO REAL DRIVE, THE VILLAGES, Florida, 32159 PREFIX TAG ID PREFIX TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETION DATE

F0880 SS = D Continued from page 15

F0880 During an interview on 1/28/2026 at 1:00 PM the Director of Nursing stated, "Staff should wash their hands in between each wound care step. The staff should take their gloves off and wash their hands and put a new pair of gloves on." During an interview on 1/28/2026 at 3:54 PM the Infectionists stated, "I would expect the staff to perform hand hygiene. I don't know why they are putting two sets of gloves on. They would need to remove both sets of gloves and put new gloves back on after washing their hands." Review of the facility policy and procedure titled "Handwashing/Hand Hygiene" with a last review date of 9/23/2025 read, "9. The use of gloves does not replace hand washing/hand hygiene." Review of the facility policy and procedure titled "Negative Pressure Wound Therapy" with a last review date of 9/23/2025 read, "Steps in the procedure: 1. Identify and size the wound to be treated. 2. Wash hands and apply gloves. 3 Clean wound according to facility protocol, or as ordered. 4. Remove gloves. 5. Wash Hands and apply clean gloves. 6. Cut sponge dressing to size."