Inspection·November 4, 2021

F 0655 (medline plus.gov; retrieved 11/04/2021). Level of Harm - Minimal harm or potential for actual harm On 11/01/21 at 10:39 AM, resident #676 complained that she was receiving a regular diet which was incorrect. She said her blood glucose was okay because did not eat those items that would raise her blood sugars. Review of the physician orders, dated 10/28/21, did not note a specific diet order. Residents Affected - Few On 11/03/21 on 4:22 PM, LPN B said she was told on report when resident #676 came from hospital, she was on regular diet. She said, I was the admitting nurse and would be responsible for putting in the diet order. Whatever was sent from hospital orders. I did not enter a diet order. 2. Resident #677 was admitted to the facility on [DATE] with diagnoses including left lower leg fracture, Cerebral infarction (stroke), chronic obstructive pulmonary disease, heart failure, hypertension, depression, and cognitive communication deficit. On 11/01/21 at 11:41 AM, resident #677 was asked if she had received a written plan of care. She said it might give been given to a family member. Review of initial admissions evaluation by nursing assessment started on 10/26/21 at 10:30 PM and signed as complete on 10/27/21 at 8:27 AM by LPN D. The area for baseline care plan had not been completed and not noted that it was shared with resident #677 or family member/health surrogate. Progress notes from 10/26/21 to 11/03/21 did not contain documentation that a baseline care plan was reviewed or given to the resident or family member. On 11/03/21 at 11:21 AM, the Minimum Data Set assessor A said she and care plan coordinator would visit the residents within a day or two of admission. They would put a note in the chart. She confirmed there was no documentation that any care plan was given to resident #677. On 11/03/21 at 4:49 PM, LPN D agreed that she was the nurse that completed the admission evaluation, and had not given a copy to the resident of her baseline plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105518 If continuation sheet Page 2 of 6 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 105518 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winter Garden Rehabilitation and Nursing Center 12751 W Colonial Drive Winter Garden, FL 34787 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to dispense oxygen as ordered for 2 of 2 residents reviewed for respiratory care in a total sample of 40 residents (#677 & 35). Residents Affected - Few Findings: 1. Resident #677 was admitted to the facility on [DATE] with diagnoses including chronic obstruction pulmonary disease (COPD), anxiety and depression. On 11/01/21 at 11:38 AM, Resident #677 sat in her wheelchair and used oxygen via an oxygen (O2) concentrator. The O2 was set between 1.25 and 1.5 liters per minute (l/min). The resident said, I use two liters per minute at home. Physician orders at 3:30 PM for O2 therapy, dated 10/27/21, was for oxygen at two liters per minute via nasal cannula continuously; monitor every shift for shortness of breath. On 11/01/21 at 3:40 PM, LPN A reviewed the order and verified the O2 should be 2 l/min. Resident #677 room was enetered at 3:43 PM, and LPN A confirmed the oxygen concentrator was set at 1.5 l/min. 2. Resident #35 was admitted on [DATE] with diagnoses including COPD and emphysema. On 11/01/21 at 3:38 PM, resident #35 sat up in her bed receiving O2 via an O2 concentrator set at 1.5 l/min. The November 2021 physician orders reflected Oxygen 2 l/min via nasal cannula continuously since 6/02/21. On 11/01/21 at 3:53 PM, LPN A said the O2 should be 2 l/min. She reviewed the order and validated the O2 concentrator should be set at 2 l/min. At 3:48 PM, LPN A agreed the concentrator was set at 1.5 l/min and should be at 2 l/min. A care plan was initiated on 6/03/21 for altered respiratory status due to COPD, and emphysema. The goal was to provide O2 as ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105518 If continuation sheet Page 3 of 6 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 105518 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winter Garden Rehabilitation and Nursing Center 12751 W Colonial Drive Winter Garden, FL 34787 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 0802 Level of Harm - Minimal harm or potential for actual harm Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview and record review, the facility failed to ensure all dietary staff were trained to operate a temporary dishwashing machine. Residents Affected - Some Findings: On 11/02/21 at 10:28 AM, the dishwashing machine was a low temperature machine. The Wash temperature was 120°F, rinse temperature was 120°F. The water very sudsy. There was no sanitizer present The Food Service Director (FSD) said that they had washed the dishes yesterday with pot and pan soap. The sanitizer did not function properly. The FSD said that the dishwashing machine changed out while she was on vacation. She had always used a high temperature dishwashing machine. She was not trained on how to operate this machine. When asked how the staff were trained to use the temporary machine. She did not have a response. On 11/02/21 at 11:33 AM, the Regional Director of Dietary Service said she would look for the and training procedures for dishwashing, and the orientation checklist. On 11/02/21 at 11:51 AM , the administrator explained, We ordered a new machine, the supplier sent us a temporary machine and a low temperature machine was the best option. An installation crew came to install it and dropped off the supplies. The old machine was leaking on electrical and needed to be removed. He was not able to identify who was managing the kitchen when the FSD was on vacation. He then said, the Dietary Supervisor (DS) would have been the designee. She was not present when the machine was installed. At approximately 12 PM the DS and the FSD were not aware as to when the machine was to be installed. The administrator and corporate person had made arrangements for the install. Neither the DS or the FSD were aware that they were going to have it installed when the FSD was not in the building. On 11/02/21 at 12:13 PM, The FSD said she came back to work 10/20/21. As soon as she came back asked for information on the machine. The installer trained the staff that were present when it was installed the DS left at 2 PM that day . She was not aware that dish washer was being installed. We were not provided with an operating manual. When I first returned I asked for assistance on the machine operation from the chemical company. On 11/02/21 at 12:21 PM the afternoon cook was present when the machine was installed. She demonstrated how to drain and fill the machine. She did not know what the chemicals were. The installers connected chemicals. She did not know when or how chemicals came in for the dishwashing machine. She validated that the rinse aid was same as the old high temperature dishwashing machine. The holder was mounted to the left of the machine. No rinse aid was observed. Lack of appropriate training on the low temperature dishwashing machine may have resulted in the potential of food borne illness due to improper washing of resident dishware. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105518 If continuation sheet Page 4 of 6 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 105518 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winter Garden Rehabilitation and Nursing Center 12751 W Colonial Drive Winter Garden, FL 34787 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to ensure the dishwashing machine was operating to properly wash and sanitize resident dishware, and failed to ensure sanitizing strips for the 3-compartment sink were not expired. Finding: 1. On 11/02/21 at 10:28 AM, the dishwashing machine revealed a low temperature with the wash temperature at 120°Fahrenheit (F) and rinse at 120°F. The test strip used for the chlorine-based sanitizer was not readable. The wash and rinse water were very sudsy. There was no sanitizer solution present. The Food Service Director (FSD) said that they washed the dishes yesterday with pot and pan soap when the correct soap was not available. She said she had just brought out a bottle of sanitizer. The label read rinse agent. The FSD said that the facility previously had a high temperature dishwashing machine. The machine was changed while she was on vacation. The facility was waiting for a new high temperature dishwashing machine. 11/02/21 at 11:17 AM, the FSD had one test strip for chlorine sanitizer that read 200 parts per million (PPM) in the dishwashing machine. The November 2021 dishwasher log noted on 11/01/21, the wash temperature for breakfast, lunch and dinner was 120°F. The sanitizer was 200 PPM for breakfast 100 PPM for lunch and 100 PPM for supper. On 11/02 21, the wash temperature was 120°F and no sanitizer was noted. The October 2021 dishwasher log noted that the low temperature machine was installed on 10/13/21. From 10/14/21 to 10/31/21, the wash temperature was always 120°F. The sanitizer was documented at 100 or 200 PPM for all three meals. Photographic evidence was provided. Review of the most recent invoice, dated 11/01/21 with a delivery date of 11/02/21, did not include the low temperature dishwashing machine soap or sanitizer. The last invoice was dated 10/12/21 with a delivery of multi- temperature machine detergent. Review of the facility Policy for Dishwashing Machine use effective 1/15/21 read in part: 4. Dishwashing machines that use chemical sanitizer to sanitize must maintain a minimum temperature of 120°F or about for any size machine with PPM concentration of the chemical sanitizer. 5 Dishwashing machine concentration and contact times for chlorine solution should have a minimum concentration of 50-100 PPM for a contact time of 10 seconds. 6. A supervisor will check the dishwashing machine for proper concentration of sanitizer solution after filling the machine and one a week thereafter. Concentrations will be record in a facility approved log. 7. Corrective action will be taken immediately. 10. If hot water or chemical sanitation concentrations do not meet requirement, cease use of dishwashing machine immediately until the temperatures or sanitizer PPM are adjusted. The potential of food borne illness was present due to improper washing of resident dishware. 2. On 11/01/21 at 9:31 AM, the three-compartment sink was set up to wash the pots and pans. When attempting to verify the sanitizing solution with the FSD, she said there was no reading, and the strips may have gotten wet. The quaternary ammonia test strips had expired in September of 2021. The FSD was not aware that the test strips had an expiration date. There were no additional testing strips (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105518 If continuation sheet Page 5 of 6 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 105518 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Winter Garden Rehabilitation and Nursing Center 12751 W Colonial Drive Winter Garden, FL 34787 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 available to check the concentration. Not using the correct sanitizer concentrations in the three-compartment sink may have the potential of food borne illnesses to the residents. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105518 If continuation sheet Page 6 of 6