Inspection·February 18, 2022

F 0692 Level of Harm - Minimal harm or potential for actual harm During an interview on 2/16/2022 beginning at 9:39 AM, the Culinary Service Manager stated the facility nursing department should provide the kitchen with a slip that documented a physician ordered diet change. She verified the frozen nutritional treat was documented on Resident #108's diet card and that Resident #108 had not received the frozen nutritional treat with meals. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105193 If continuation sheet Page 2 of 9 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105193 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Meadows Healthcare & Rehabilitation Center 3250 SW 41st Place Gainesville, FL 32608 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services for 2 of 4 residents reviewed for enteral nutrition, Residents #48 and #488, in a total sample of 41 residents. Findings: 1. During an observation on 2/15/2022 at 3:30 PM, Resident #48's Isosource formula bag did not have a resident name, the date or time the formula was hung, the name of the formula, or the name of the nurse that hung the enteral feeding. The bag had a balance of 900 ML. During an interview on 2/15/2022 at 3:35 PM, Staff E, Licensed Practical Nurse (LPN), stated, I do not know why the resident's enteral feeding bag does not show the date the formula was hung, time the formula was hung, name of the formula, resident name or the name of the nurse that hung the feeding. The resident's name, time the feeding was hung, the date the feeding was hung, the name of the formula and the name of the nurse that hung the bag should be on the bag. 2. During an observation on 2/15/2022 at 12:30 PM, Resident #488's Isosource formula bag was not infusing. The bag did not have the name of the formula, date/time, the nurse's name or the resident identifier on the bag. During an observation on 2/15/2022 at 3:30 PM, Resident #488's Isosource formula bag was not infusing. The head of the resident's bed was elevated. During an observation on 2/15/2022 at 4:00 PM, when the previous bag for Resident #488 was removed, it did not show the name of the resident, name of the formula, date/time, or the name of the nurse on the bag. The 1000 ML bag had 200 ML infused out of 1000 ML, leaving a balance of 800 ML. Per calculation of the formula, if the formula was hung at 4:00 PM as ordered and discontinued at 12:00 PM as ordered (a new bag would have had to be hung because the bags were 1000 ML), the balance of the formula should have been 600 ML. During an interview on 2/15/2022 at 4:32 PM, Staff E, LPN, stated, I do not know why the resident's enteral feeding bag does not show the date the formula was hung, time the formula was hung, name of the formula, resident name or the name of the nurse that hung the feeding. The resident's name, time the feeding was hung, the date the feeding was hung, the name of the formula and the name of the nurse that hung the bag should be on the bag. During an interview on 2/15/2022 at 5:00 PM, Staff E, LPN, stated, I do not see the name of the formula, date the feeding was hung, rate to run the formula, the name of the nurse that hung the formula. The resident should have had a balance of 600 ML left to infuse. Review of Resident #488's Medication Administration Record (MAR) reads, Two times a day Isosource 1.5 via feeding tube at 70 cc [milliliter]/hour for 20 hours (4P-12P [4 PM to 12 PM]) with autoflushes at 60 cc/hour X 20 hours (4P-12P). Review of the facility policy and procedure titled Enteral Nutrition revised in November 2018 reads, Policy Statement: Adequate nutritional support through enteral nutrition is provided to residents (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105193 If continuation sheet Page 3 of 9 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105193 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Meadows Healthcare & Rehabilitation Center 3250 SW 41st Place Gainesville, FL 32608 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 as ordered. Policy Interpretation and Implementation: . 11. The Nurse confirms that orders for enteral nutrition are complete. Complete orders include: . d. Volume and rate of administration. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105193 If continuation sheet Page 4 of 9 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105193 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Meadows Healthcare & Rehabilitation Center 3250 SW 41st Place Gainesville, FL 32608 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on record review and interview, the facility failed to ensure the attending physician documented review of the pharmacist's recommendation, action taken in response to the pharmacist's recommendation or rationale for no action taken in response to the pharmacist's recommendation for 1 of 5 residents reviewed for unnecessary medications, Resident #25, in a total sample of 41 residents. Findings: Review of the pharmacy consultation report dated 11/23/2021 for Resident #25 revealed the pharmacist's recommendation that Resident #25's use of Omeprazole 20 milligrams via g tube daily for greater than 12 weeks be reviewed and the necessity for continuation documented as well as monitoring done for any adverse consequences. The pharmacy consultation report did not reveal any documentation that the pharmacist's recommendation had been reviewed, accepted or declined by the attending physician. During an interview on 2/17/2022 at 10:44 AM, the Director of Nursing stated the attending physician had reviewed Resident #25's medication regimen twice during November 2021 but had not documented review of the pharmacist's recommendation, action taken in response to the pharmacist's recommendation or rationale for no action taken in response to the pharmacist's recommendation. Review of the facility policy and procedure titled Medication Regimen Reviews last reviewed on 1/3/2022 reads, Policy Interpretation and implementation: . 4. The goal of MMR [Medication Regiment Review] is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication . 12. The attending physician documents in the medical record that the irregularity has been reviewed and what (if any) action was taken to address it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105193 If continuation sheet Page 5 of 9 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105193 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Meadows Healthcare & Rehabilitation Center 3250 SW 41st Place Gainesville, FL 32608 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles and included expiration date, when applicable, in 4 of 6 medication carts. Findings: On [DATE] at 9:10 AM, the surveyor observed Station 3 Medication Cart with Staff A, Licensed Practical Nurse (LPN), and found one opened one-ounce tube of triple antibiotic ointment with no resident identifier or no opened date, and one opened Lantus insulin pen for Resident #42 with no opened date. During an interview on [DATE] at 9:20 AM, Staff A, LPN, stated, All insulin should have the date the insulin was opened. The triple antibiotic ointment should have the name of the resident on it and the directions for use, and the date the antibiotic ointment was opened. On [DATE] at 9:37 AM, the surveyor observed Station 2 Medication Cart with Staff B, LPN, and found one narcotic card containing 22 Tramadol 50 MG [milligrams] for Resident #105 that was expired on [DATE], one opened Lantus insulin pen for Resident #47 with no opened date, and one opened Novolog insulin Pen for Resident #47 with no opened date. During an interview on [DATE] at 9:43 AM, Staff B, LPN, stated, I do not know why the narcotic is expired for [Resident#105's name]. I do not know why the insulin for [Resident #47's name] did not show the date the Lantus and Novolog insulin was opened. The insulins should have been dated when the insulin was opened. On [DATE] at 9:56 AM, the surveyor observed Station 4 Medication Cart with Staff C, LPN, and found one opened Erythromycin 3.5 gm (gram) ophthalmic ointment for Resident #124 with no opened date, one opened Lantus insulin pen for Resident #124 with no opened date, one unopened Lantus insulin pen for Resident #124 with the instructions to refrigerate, one opened Humalog insulin for Resident #124 with an opened date of [DATE] and expiration date of [DATE], one opened 3.5 ML (milliliter) Combigan eye drops for Resident #124 with no opened date, one opened Moxifloxacin eye ointment for Resident #124 with no opened date, and one opened Novolog insulin 10 ML for Resident #117 with an opened date of [DATE] and expiration date of [DATE]. During an interview on [DATE] at 10:15 AM, Staff C, LPN, stated, I do not know why the insulins are opened in the working stock drawer and are not dated. I don't know why the insulin for [Resident #117's name and Resident#124's name] was in the working stock drawer past the expiration of the insulin. The insulins should be removed from the drawer after they are expired. I do not know why the eye drops for [Resident #124's name] did not have a date as to when the eye drops were opened. Insulin should be dated. Eye drops should be dated. On [DATE] at 10:15 AM, the surveyor observed Station 1 Medication Cart with Staff D, LPN, and found one opened insulin Aspart for Resident #94 with no opened date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105193 If continuation sheet Page 6 of 9 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105193 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Meadows Healthcare & Rehabilitation Center 3250 SW 41st Place Gainesville, FL 32608 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm During an interview on [DATE] at 10:23 AM, staff D, LPN, stated, I have no idea why the insulin for [Resident #94's name] did not show the date the insulin was opened. On [DATE] at 12:53 PM, the surveyor observed Station 1 Medication Cart and found one unopened Insulin Aspart Pen for Resident #171 with the directions to refrigerate. Residents Affected - Some During an interview on [DATE] at 1:06 PM, the Unit Manager of Station 1 stated, A nurse ordered the insulin on [DATE] and did not refrigerate it when it arrived at the facility. The insulin should be refrigerated until it is opened. Review of the facility policy and procedure titled Administering Medications last revised on [DATE] reads, Policy Interpretation and Implementation: . 9. The expiration/beyond use date on the medication label must be checked prior to administering medications. When opening a multi-dose container, the date opened shall be recorded on the container . 13 . In addition, dates for expiration for medication will be checked, not to exceed 28 days for all insulins per policy. Both dates for opening and expiration will be listed on the insulin. Review of the facility policy and procedure titled Storage of Medications last revised on [DATE] reads, Policy Interpretation and Implementation: . 11. Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secured location. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105193 If continuation sheet Page 7 of 9 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105193 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Meadows Healthcare & Rehabilitation Center 3250 SW 41st Place Gainesville, FL 32608 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0801 Level of Harm - Minimal harm or potential for actual harm Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on record review and interview, the facility failed to ensure the director of food and nutrition services met the requirements to carry out the functions of the food and nutrition services. Residents Affected - Many Findings: Review of the facility personnel roster revealed the facility Culinary Service Manager was hired on 7/26/2021 and designated as dietary staff. Review of the facility Culinary Service Manager's job description revealed the Culinary Service Manager was responsible for The day-to-day coordination and oversight of all aspects of the Culinary Service Department. The Culinary Service Manager's job description documented requirements for the position that included, Proven experience as a manager and meets all educational requirements needed for position. During an interview on 2/14/2022 at 9:43 AM, the Culinary Service Manager stated that she was not a Certified Dietary Manager. She stated that she had a culinary degree. Review of the letter dated 8/1/2006 presented by the Culinary Service Manager as proof of qualifications to hold the position documented the Culinary Service Manager had graduated with an Associate of Arts degree in culinary arts on June 1, 2003. During an interview on 2/16/2022 at 2:14 PM, the Administrator confirmed that the staff member contracted as the Culinary Service Manager was not a Certified Dietary Manager and did not have an associates or higher degree in food service management or hospitality that included food service or restaurant management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105193 If continuation sheet Page 8 of 9 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105193 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Meadows Healthcare & Rehabilitation Center 3250 SW 41st Place Gainesville, FL 32608 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure foods were stored in a sanitary manner in the kitchen and in 1 of 3 nourishment rooms (100 Hall). Residents Affected - Many Findings: During the initial tour of the facility kitchen with the Culinary Service Manager on 2/14/2022 at 10:00 AM, there was a black and grey scattered substance on the plastic guard in the ice machine. During an interview on 2/14/2022 at 10:00 AM, the Culinary Service Manager acknowledged the black and grey substance on the plastic guard of the ice machine. During an observation with the Culinary Service Manager on 2/14/2022 at 10:02 AM, there was an unlabeled and undated canvas bag of wrapped food items and an undated sandwich stored in the refrigerator of the 100 Hall nourishment room. There was an unlabeled and undated Styrofoam bowl of a substance on the counter in the 100 Hall nourishment room. During an interview on 2/14/2022 at 10:02 AM, the Culinary Service Manager confirmed the findings observed in the 100 Hall nourishment room. Review of the facility policy and procedure titled Food Receiving and Storage last reviewed on 1/3/2022 reads, Policy Interpretation and Implementation: 1. Food Services, or other designated staff, will maintain clean food storage areas at all times. Review of the facility policy and procedure titled Food Brought by Family/Visitors last reviewed on 1/3/2022 reads, Policy Interpretation and Implementation: . 7. Food brought by family/visitors that is left with the resident to consume later will [be] labeled and stored in a manner that is clearly distinguishable from facility prepared food. a. Non-perishable foods will be stored in re-sealable containers with tight-fitting lids. Intact fresh fruit may be stored without a lid. b. Perishable foods must be stored in re-sealable containers with tight-fitting lids in a refrigerator. Containers will be labeled with the resident's name, the item and the use by date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105193 If continuation sheet Page 9 of 9