Inspection·February 2, 2026

K0000 INITIAL COMMENTS K0000 02/05/2026 An unannounced re-licensure survey was conducted on 2/2/26 at Freedom Pointe Health Center, a nursing home, in The Villages, Florida in accordance with National Fire Protection Association (NFPA) 1 and 101 (2021 Edition) and applicable requirements of Florida State Fire Marshal's Rules and Regulations, Florida Administrative Code (F.A.C.) 69A-3, F.A.C. 69A-53, F.A.C. 59A-4, and Florida Statutes (F.S.) 400 Part II, and F.S. 633.0215, adopting NFPA 1 and 101 (2021 Edition) known as the Florida Fire Prevention Code and all NFPA referenced standards and requirements adopted per NFPA 101, Chapter 2. Following is a description of the deficiencies.

K0345 SS = E Fire Alarm System - Testing and Maintenance K0345 02/28/2026 CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance Detection systems, where required, shall be in accordance with Section 9.6. Fire alarm systems required by this Code shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA70 and NFPA72 unless otherwise permitted by 9.6.1.4. 18.3.4.1, 19.3.4.1, 9.6, and NFPA 70, and NFPA 72 This LICENSURE REQUIREMENT IS NOT MET as evidenced by: Based on record review and staff interview, the facility failed to test fire alarm interface equipment in accordance with NFPA 72. This in the event of a fire could result in the smoke detection devices failing to operate as designed thereby endangering the occupants of the building. This affects all smoke compartments of the building. Findings include: Review of the facility fire alarm inspection reports, the reports did not include results for the air stream testing of the duct smoke detectors. 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. Facility Plan of Correction K-Tag: K0345 – Fire Alarm System (NFPA 72 Testing – Duct Smoke Detector Differential Pressure Testing) 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: No residents were identified as having been harmed by this deficient practice. The finding was related to required inspection and documentation of fire alarm interface equipment testing and not an actual failure of the fire alarm system. Upon identification of the deficiency, the facility Office of Primary Care and Health Systems Management

K0345 SS = E Continued from page 1 K0345 Continued from page 1 During an interview on 2/2/26 at 1:06 PM while reviewing the fire alarm inspection reports, the Maintenance Director stated that the testing was "not done." NFPA 101 (2018 edition) 19.5.2.1, 9.2, NFPA 72 (2016 edition) Table 14.4.3.2.17 (g)(5) Class III 1. Immediately contacted its qualified fire alarm service provider to perform the required testing of duct smoke detectors, including differential pressure testing in accordance with NFPA 72. 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 the fire alarm system protects the entire building, all residents had the potential to be affected. The facility conducted a review of fire alarm inspection reports and life safety documentation to verify that required testing components were completed. Any missing or incomplete testing documentation was addressed through follow-up with the fire alarm vendor on 2/13/2026 and testing will be scheduled. 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: A life safety inspection tracking log and calendar was developed to identify all required testing and inspection frequencies. The facility will ensure inspection reports received from vendors clearly document completion of required testing components, including duct smoke detector testing. Maintenance and administrative staff responsible for life safety compliance were reeducated on documentation and inspection verification requirements. Life safety inspection records will be reviewed upon receipt and maintained in a centralized location for survey readiness. 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) Florida Department of Health FREEDOM POINTE HEALTH CENTER 1460 EL CAMINO REAL DRIVE, THE VILLAGES, Florida, 32159

K0345 SS = E

K0345 Continued from page 2 program. Maintenance Director or designee will review life safety inspection documentation after each inspection to verify completeness. Weekly audits will be conducted for four (4) weeks to ensure required documentation is present and complete. Monthly audits will then be conducted for three (3) months. Thereafter, quarterly audits will be completed as part of the ongoing life safety compliance program. Results of audits will be reported to the QAPI committee, and any identified concerns will be addressed promptly with corrective action and vendor follow-up as necessary. The QAPI Committee will continue monitoring until three consecutive quarters demonstrate 100% compliance. Thereafter, monitoring will continue on a quarterly basis as part of the facility’s ongoing Life Safety compliance program.

K0761 SS = E Bldg. 05 Maintenance Inspection & Testing - Doors CFR(s): NFPA 101 Fire door assemblies shall be installed, inspected, tested, and maintained in accordance with NFPA 80. All fire door assemblies shall be labeled. Labels on fire door assemblies shall be maintained in a legible condition. In existing installations, steel door frames without a label shall be permitted where approved by the authority having jurisdiction. Unless otherwise specified, fire doors shall be self-closing or automatic-closing. Doors, other than those listed in 8.2.2.4 and 8.3.3.1, that are required to be self-closing or automatic closing shall comply with all of the following: (1) Door assemblies shall be inspected annually. (2) Doors shall be operated to confirm full closure. (3) Parts found to be damaged or inoperative shall be

K0761 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. K-Tag: K0761 – Fire Dampers (NFPA 101 / NFPA 80 Inspection and Maintenance) 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: No residents were identified as having been harmed by this deficient practice. The finding involved incomplete inspection and documentation of fire dampers and not an actual fire event. 02/28/2026 STATE FORM FREEDOM POINTE HEALTH CENTER 1460 EL CAMINO REAL DRIVE, THE VILLAGES, Florida, 32159 CROSS-REFERENCED TO THE COMPLETION DATE

K0761 Continued from page 3 SS = E replaced. Bldg. 05 (4) Door openings and the surrounding areas shall be kept clear of anything that could obstruct or interfere with the free operation of the door. (5) Blocking or wedging of doors in the open position shall be prohibited. (6) Self-closing and automatic-closing devices shall be kept in working condition at all times. Written records of inspection and testing are maintained and available for review. 19.7.6, 4.6.12.1, 8.3.3.3 through 8.3.3.3.5, 8.5.4.3, 8.5.4, 8.7.1.3, 8.8 (NFPA 101) 5.2, 5.2.3 (NFPA 80) This LICENSURE REQUIREMENT is NOT MET as evidenced by: Based on observation, record review and staff interview, the facility failed to inspect and maintain fire dampers in accordance with the applicable provisions of NFPA 101 and NFPA 80. This may cause the dampers to fail to act as designed in the event of a fire would allow the passage of fire, smoke and fire gasses to travel to multiple parts of the building. This practice affects all smoke compartments in the building. Findings include: Review of the maintenance logs, records for fire damper inspections documented 14 of 28 fire dampers were inspected. During an interview on 2/2/26 at 1:18 PM the Maintenance Director acknowledged and concurred with the findings. NFPA 101 (2021 Edition) 19.7.6, 8.3.3.1; NFPA 80 (2019 Edition) 19.4 Class III K0761 Continued from page 3 Immediate identification of the deficiency, the facility contacted a qualified, licensed fire protection contractor to inspect the fire dampers throughout the building. Fire dampers that had not previously been inspected were located, accessed, and inspected in accordance with NFPA 80 requirements. The contractor completed an on-site inspection and functional testing on 02/13/2026. 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 fire dampers protect smoke compartments throughout the building, all residents had the potential to be affected. The facility conducted a complete building review to identify and inventory all fire dampers. A comprehensive fire damper inventory list, including locations, access points, and identification numbers, was reviewed. All dampers will be verified as inspected, operational, and documented on 02/13/2026 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: A life safety equipment inventory was created identifying all fire dampers and their locations within the building. A preventive maintenance schedule and tracking log was developed to ensure all fire dampers are inspected at required intervals in accordance with NFPA 80. The facility will utilize qualified fire protection contractors for inspection and maintenance of fire dampers. Maintenance and administrative staff responsible for life safety compliance were reeducated on fire damper inspection frequency and documentation requirements. Life safety inspection reports will be reviewed upon receipt to ensure completeness and maintained in a centralized life safety compliance file. Florida Department of Health PRINTED: 04/03/2026 FREEDOM POINTE HEALTH CENTER 1460 EL CAMINO REAL DRIVE, THE VILLAGES, Florida, 32159 APPROPRIATE DEFICIENCY)

K0761 [blank] K0761 Continued from page 4 SS = E Bldg. 05 [blank] 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. A designated staff member will review all fire damper inspection reports upon receipt to verify inspections were completed and documented. Weekly audits will be conducted for four (4) weeks to ensure the fire damper inventory and documentation remain complete and accessible. Monthly audits will be conducted for three (3) months to verify the preventive maintenance schedule is maintained. Thereafter, quarterly audits will be conducted as part of the ongoing life safety compliance program. The QAPI Committee will continue monitoring until three consecutive quarters demonstrate 100% compliance. Thereafter, monitoring will continue on a quarterly basis as part of the facility’s ongoing Life Safety compliance program. 106083 02/02/2026 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

K0000 INITIAL COMMENTS

K0000 02/05/2026 An unannounced Fire & Life Safety recertification survey was conducted on 2/2/26 at Freedom Pointe Health Center, a nursing home in The Villages, Florida. Freedom Pointe Health Center is not in compliance with 42 CFR 483.90 (a) and National Fire Protection Association (NFPA) 101 (2012 Edition), NFPA 99 (2012 Edition) requirements for nursing homes. Initial Plan Review: 2008 Existing NFPA 220 Construction Type: II (000) Number of beds: 72 Census: 68 The following is description of the noncompliance.

K0345 SS = E Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This STANDARD is NOT MET as evidenced by: Based on record review and staff interview, the facility failed to test fire alarm interface equipment in accordance with NFPA 72, in the event of a fire could result in the smoke detection devices failing to operate as designed thereby endangering the occupants of the building. This affects all smoke compartments.

K0345 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. 02/28/2026 Facility Plan of Correction K-Tag: K0345 – Fire Alarm System (NFPA 72 Testing – Duct Smoke Detector Differential Pressure Testing) 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: No residents were identified as having been harmed by 1460 EL CAMINO REAL DRIVE, THE VILLAGES, Florida, 32159

K0345 SS = E Continued from page 1 K0345 Continued from page 1 Findings include: Review of the facility fire alarm inspection reports, the reports did not include results for the differential pressure testing of the duct smoke detectors. During an interview on 2/2/26 at 1:06 PM while reviewing the fire alarm inspection reports, the Maintenance Director stated that the testing was "not done." Differential pressure testing of tube type duct detectors is a requirement of: NFPA 72 (2010 edition) Table 14.4.2.2-14 (g)(6). NFPA 101(2012 edition) 19.5.2.1, 9.2, NFPA 72 (2010 edition) Table 14.4.2.2-14(g)(6) this deficient practice. The finding was related to required inspection and documentation of fire alarm interface equipment testing and not an actual failure of the fire alarm system. Upon identification of the deficiency, the facility immediately contacted its qualified fire alarm service provider to perform the required testing of duct smoke detectors, including differential pressure testing in accordance with NFPA 72. 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 the fire alarm system protects the entire building, all residents had the potential to be affected. The facility conducted a review of fire alarm inspection reports and life safety documentation to verify that required testing components were completed. Any missing or incomplete testing documentation was addressed through follow-up with the fire alarm vendor on 2/13/2026 and testing will be scheduled. 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: A life safety inspection tracking log and calendar was developed to identify all required testing and inspection frequencies. The facility will ensure inspection reports received from vendors clearly document completion of required testing components, including duct smoke detector testing. Maintenance and administrative staff responsible for life safety compliance were reeducated on documentation and inspection verification requirements. Life safety inspection records will be reviewed upon receipt and maintained in a centralized location for survey readiness. 106083 02/02/2026 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

K0345 SS = E

K0345 Continued from page 2 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. Maintenance Director or designee will review life safety inspection documentation after each inspection to verify completeness. Weekly audits will be conducted for four (4) weeks to ensure required documentation is present and complete. Monthly audits will then be conducted for three (3) months. Thereafter, quarterly audits will be completed as part of the ongoing life safety compliance program. Results of audits will be reported to the QAPI committee, and any identified concerns will be addressed promptly with corrective action and vendor follow-up as necessary. The QAPI Committee will continue monitoring until three consecutive quarters demonstrate 100% compliance. Thereafter, monitoring will continue on a quarterly basis as part of the facility’s ongoing Life Safety compliance program.

K0761 SS = E Bldg. 01 Maintenance, Inspection & Testing - Doors CFR(s): NFPA 101 Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review.

K0761 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. K-Tag: K0761 – Fire Dampers (NFPA 101 / NFPA 80 inspection and Maintenance) 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: 106083 02/02/2026 FREEDOM POINTE HEALTH CENTER 1460 EL CAMINO REAL DRIVE, THE VILLAGES, Florida, 32159 TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE

K0761 Continued from page 3 SS = E K0761 Bldg. 01 Continued from page 3 No residents were identified as having been harmed by this deficient practice. The finding involved incomplete inspection and documentation of fire dampers and not an actual fire event. Immediate identification of the deficiency, the facility contacted a qualified, licensed fire protection contractor to inspect the fire dampers throughout the building. Fire dampers that had not previously been inspected were located, accessed, and inspected in accordance with NFPA 80 requirements. The contractor completed an on-site inspection and functional testing on 02/13/2026. 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 fire dampers protect smoke compartments throughout the building, all residents had the potential to be affected. The facility conducted a complete building review to identify and inventory all fire dampers. A comprehensive fire damper inventory list, including locations, access points, and identification numbers, was reviewed. All dampers will be verified as inspected, operational, and documented on 02/13/2026. 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: A life safety equipment inventory was created identifying all fire dampers and their locations within the building. A preventive maintenance schedule and tracking log was developed to ensure fire dampers are inspected at required intervals in accordance with NFPA 80. The facility will utilize qualified fire protection contractors for inspection and maintenance of fire dampers. Maintenance and administrative staff responsible for life safety compliance were reeducated on fire damper 19.7.6, 8.3.3.1 (LSC) 5.2, 5.2.3 (2010 NFPA 80) This STANDARD is NOT MET as evidenced by: Based on record review and staff interview, the facility failed to inspect and maintain fire dampers in accordance with the applicable provisions of NFPA 101 and NFPA 80. This may cause the dampers to fail as designed and in the event of a fire will allow the passage of fire, smoke and fire gasses to travel to multiple parts of the building. This practice affects all smoke compartments in the building. Findings include: Review of the maintenance logs, records for fire damper inspections documented 14 of 28 fire dampers were inspected. During an interview on 2/2/26 at 1:18 PM the Maintenance Director acknowledged and concurred with the findings. NFPA 90A (2012 edition) 5.4.8; NFPA 80 (2010 edition) 19.4.1.1 Class III 106083 02/02/2026 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

K0761 SS = E Bldg. 01

K0761 Continued from page 4 inspection frequency and documentation requirements. Life safety inspection reports will be reviewed upon receipt to ensure completeness and maintained in a centralized life safety compliance file. 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. A designated staff member will review all fire damper inspection reports upon receipt to verify inspections were completed and documented. Weekly audits will be conducted for four (4) weeks to ensure the fire damper inventory and documentation remain complete and accessible. Monthly audits will be conducted for three (3) months to verify the preventive maintenance schedule is maintained. Thereafter, quarterly audits will be conducted as part of the ongoing life safety compliance program. The QAPI Committee will continue monitoring until three consecutive quarters demonstrate 100% compliance. Thereafter, monitoring will continue on a quarterly basis as part of the facility's ongoing Life Safety compliance program. 02/02/2026 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

E0000 Initial Comments

E0000 02/05/2026 During the recertification survey conducted on 2/2/26 at Freedom Pointe Health Center, a nursing home, the Emergency Preparedness Program (EP) was reviewed. Freedom Pointe Health Center is in compliance with the Emergency Preparedness rule per Code of Federal Regulations (CFR) 42, Part 483.70, Requirement for Long-Term Care Facilities.