Inspection·September 25, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the dining room. Resident expressed his appreciation. Stated he would take a break from attending dining room for a bit. Psych [psychiatric] consult and 30 min [minute] safety checks initiated. Resident provided with dining room coverage. On 9/29/24/25 at 4:33 PM, the Certified Dietary Manager (CDM) said For a period of time [resident #5] was not in the dining room for a problem that happened. She indicated she was not present when the incident occurred, but he would be allowed to return to the dining room the first week of October. She stated resident #5 previously ate meals in the dining room. She explained she learned about the incident during a meeting. The CDM stated in her three years at the facility, she had never seen any other residents restricted from eating in the dining room. On 9/25/25 at 1:09 PM, Restorative Certified Nursing Assistant (CNA) B stated she often saw resident #5 seated and interacting with others in the dining room whenever she worked. She recalled going to resident #5's room the day after the incident happened and learning he could not go to the dining room for 30 days. She recalled the resident explained to her that he became upset that day because he was hungry, and the food was taking too long to be served. On 9/25/25 at 2:02 PM, in a telephone interview, Registered Nurse (RN) C shared that on 8/29/25 after the incident occurred, she was surprised to learn about resident #5's behavior that night. She indicated he was probably upset about the service and just had enough. She stated the facility restricted him from eating meals in the dining room for 30 days. The nurse said she learned about the restriction from upper management, resident #5's former roommate and resident #5 himself. On 9/25/25 at 2:25 PM, resident #11 stated she had been the Resident Council President for one year and usually ate her lunch and dinner in the dining room. She confirmed some residents had expressed the food was not served timely or hot in previous Resident Council meetings. She validated she was present during the incident on 8/29/25 and was upset that people might get hurt. She recalled that staff had to restrain resident #5 and told him to go to his room. The Resident Council President explained they had a Resident Council meeting the morning after the incident and were informed resident #5 would not come to the dining room for about a month. She shared everyone at the meeting was in agreement with the decision. She said, His punishment ended early, and he returned to the dining room yesterday. On 9/25/25 at 2:40 PM, resident #12 said people in the kitchen do not listen or care. He confirmed they had shared concerns during meetings but felt nothing was done. He recalled resident #5 got upset because there was no one to serve the food. He stated all the residents in the dining room were upset that night. Resident #12 indicated he walked down to get the nursing staff to serve them dinner but could not find anyone at first, then his assigned nurse informed him someone would go to the dining room. He stated when he returned to the dining room, resident #5 was cursing, moving chairs and tables, and a female resident pushed him with her walker. Resident #12 said he learned in a Resident Council meeting that resident #5 was banned for 30 days. On 9/25/25 at 2:59 PM, resident #5 elaborated the kitchen staff refused to serve them and the food was getting cold. He indicated he was frustrated with too many rules. He reiterated he was told he had a 30-day suspension of eating in the dining room and other activities like outings to restaurants and such. He said his suspension from the dining room was announced to everyone. He shared he did not remember when the suspension was up and went once to the dining room, sat with other residents, but was taken aside and reminded his time to return was not up yet, so he had to return to his room to eat his meal. He stated he felt he was treated like he was a child. Resident #5 expressed at the time he was mad, but it didn't matter because he was leaving the facility in a few days. On 9/25/25 at 10:58 AM, the Administrator (NHA) stated she was not present when the incident occurred, but when called, she returned to the facility. She recalled the Social Services Director informed her resident #5 was upset the CNA was not in the dining room timely. She indicated resident #5 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105518 If continuation sheet Page 2 of 3 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 09/25/2025 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete told them he was testing out his acting skills because the CNA was late and he thought that would be funny. The NHA stated she educated resident #5 and told him his behavior was inappropriate and disrespectful to other residents. She shared he thought other residents would find it funny and he was now embarrassed, so he did not want to return to his room because his roommate was in the dining room when the incident happened. She stated resident #5 was offered a room change which he accepted. The NHA stated she was unaware resident #5 thought he could not eat his meals in the dining room. The NHA denied making the decision to prohibit resident #5 to eat his meals in the dining room for 30 days and could not explain why resident #5, other residents, and staff would say that. She shared it was resident #5 who stated he would take a break from going to the dining room. On 9/25/25 at 5:34 PM, during a telephone interview, the former Director of Nursing (DON) explained she was not present when the incident occurred, but she returned to the facility shortly after. She stated the kitchen corroborated nursing staff was not in the dining room when the dinner trays were brought out but said they arrived within five minutes. She said the nurse who came to serve the residents did not know the process and started passing coffee instead of the trays, and resident #5 went ballistic. She stated he was placed in another room temporarily and she received physician orders for laboratory tests and a psychiatric evaluation. She stated the NHA came after she had left and added steps to keep everyone safe. She recalled having a Resident Council meeting the next morning which resident #5 attended. She indicated she explained the new plan they implemented to make the dining process smoother. She shared he was such a mild manner man and they were surprised by his behavior. She indicated she felt once they resolved the dining room process, everything would be okay. She said not allowing him to return to the dining room for his meals for 30 days was extreme, but it was not her decision. She stated he enjoyed doing eating in the dining room, and they informed resident #5 he could participate in certain activities but could not eat his meals in the dining room or go on outings. Review of the minutes for an Emergency Resident Council Meeting held on 8/30/25 revealed 12 residents attended including the Resident Council President and resident #5. The form showed residents expressed concerns about the previous evening event and overall meal delivery. The DON shared their new plan to be implemented to ensure a smooth process in the dining room. The residents agreed with the plan. Review of the facility's Resident Rights policy and procedure revised on January 2024 read, A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the residents. Event ID: Facility ID: 105518 If continuation sheet Page 3 of 3