Health inspection·December 18, 2020

F 0641 for Restraints indicated that bed rails were not used. Level of Harm - Minimal harm or potential for actual harm A review of Resident #51's care plan identified the resident was at risk for falls related to: decreased lower extremity strength, unsteady balance, decreased functional Range Of Movement (ROM) bilateral upper and lower extremities, impaired cognition, impaired mobility, contracture left ankle, psychoactive medication (med) use, and parkinsons. This focus was initiated and revised on 12/14/19. The interventions related to the focus included re-position to the middle of the bed as needed to prevent sliding from the bed, initiated on 6/12/20. The care plan indicated the resident had an Activity of Daily Living (ADL) Self-care and mobility deficit with the need for extensive to total assistance with ADL completion on daily basis. At risk of developing complications associated with decreased ADL self-performance related to: cognitive impairment, weakness, impaired mobility, poor coordination and endurance, Parkinson's, decreased functional ROM bilateral upper and lower extremities, psychoactive med use, initiated 2/1/19 and revised 12/2/19. The resident has behavior problems related to placing self on the floor, initiated and revised on 3/30/20. The active care plan for Resident #51 did not identify the use of bilateral 1/4 Bed/Adaptive Rails. Residents Affected - Few On 12/18/20 at 1:17 p.m., the Director of Nursing (DON) stated the facility evaluates for adaptive/bed rails on admission and quarterly. She stated the facility does not obtain consent for the rails quarterly and does speak with the representatives or the resident quarterly. She reported that the assessment for Adaptive/Bed rails should portray the resident correctly. The DON reviewed the Adaptive Rail Screen, completed on 9/25/20, and confirmed that the screen did not portray Resident #51 correctly. The policy titled, Adaptive Rail Guideline, effective 11/28/2017 and revised on 10/14/19, identified, It is the standard of this center to ensure the safe use of adaptive rails as resident mobility aids and to prohibit the use of adaptive rails as restraints. The protocol of the policy included the following: - 1. Adaptive rails are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents; - 2. The adaptive rail will be monitored, evaluated, and reviewed for initial and ongoing needs by the clinical team; - 4. An assessment/evaluation/screen will be made to determine the resident's symptoms or reason for using adaptive rails; - 6. Pertinent information related to adaptive rail utilization should be documented in the resident's clinical record; - 7. Use of adaptive rails as an assistive device should be present in the resident-centered plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105566 If continuation sheet Page 2 of 20 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 105566 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Winter Haven 1120 Cypress Gardens Blvd Winter Haven, FL 33884 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews the facility failed to review and revise a comprehensive, person-centered care plan by not including an intervention of adaptive/bed rails for one resident (#51) of 28 sampled residents. Findings included: Resident #51 was initially admitted on [DATE] and re-admitted on [DATE]. The admission Record included diagnoses of Parkinson's Disease, generalized weakness, unspecified lack of coordination, right knee contracture, and left knee contracture. An observation on 12/15/20 at 10:36 a.m., revealed Resident #51 was lying in a low bed with floor mats on each side of the bed and 1/4 bed/adaptive rails raised bilaterally. The Adaptive Rail Screen, with an effective date of 2/7/20, indicated the use of adaptive rails were considered due to a medical symptom and the resident's physical need for the rails was due to weakness, the cognitive reason was checked as none, and had a history of rolling out of bed. The screen indicated the resident requested the adaptive rails and the risks and benefits of rail use was discussed with the resident and the family/resident representative. The Adaptive Rail Screen, with an effective date of 9/25/20, indicated the family requested the use of adaptive rails for safety/security. The latest screen (9/25/20) indicated none for the need for the use of adaptive rails for physical, cognitive and sense of security. The screen on 9/25/20 did not indicate that the resident had a history of rolling out of bed. Neither of the screens indicated that the resident was taking any medications that would require increased safety measures (i.e., diuretics, psychotropics, etc.) or that there was a decline in cognitive status affecting safety awareness. The current screen indicated that adaptive rails were not indicated at this time. The clinical record for the resident did not include a quarterly screen/evaluation for the continued use of Adaptive/Bed rails during the seven month period between the screens completed on 2/7/20 and 9/25/20. The physician Order Summary dated 12/18/20 indicated Resident #51 was prescribed, on 9/25/20, the diuretic medication, Furosemide. The summary did not identify a physician order for the use of Adaptive/Bed rails. The Quarterly Minimum Data Set (MDS), dated [DATE], indicated that Resident #51 had a Brief Interview of Mental Status score of 6, indicative of severe cognitive impairment. The MDS in Section G for Functional Status identified the resident required extensive assist by one-person for bed mobility and transfers and had active diagnoses of non-Alzheimer's dementia and Parkinson's Disease. Section P for Restraints indicated that bed rails were not used. A review of Resident #51's care plan identified the resident was at risk for falls related to: decreased lower extremity strength, unsteady balance, decreased functional Range Of Movement (ROM) bilateral upper and lower extremities, impaired cognition, impaired mobility, contracture left ankle, psychoactive medication (med) use, and parkinsons. This focus was initiated and revised on 12/14/19. The interventions related to the focus included re-position to the middle of the bed as needed to prevent sliding from the bed, initiated on 6/12/20. The care plan indicated the resident had an Activity of Daily Living (ADL) Self-care and mobility deficit with the need for extensive to total (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105566 If continuation sheet Page 3 of 20 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 105566 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Winter Haven 1120 Cypress Gardens Blvd Winter Haven, FL 33884 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few assistance with ADL completion on daily basis. At risk of developing complications associated with decreased ADL self-performance related to: cognitive impairment, weakness, impaired mobility, poor coordination and endurance, Parkinson's, decreased functional ROM bilateral upper and lower extremities, psychoactive med use, initiated 2/1/19 and revised 12/2/19. The resident has behavior problems related to placing self on the floor, initiated and revised on 3/30/20. The active care plan for Resident #51 did not identify the use of bilateral 1/4 Bed/Adaptive Rails. On 12/18/20 at 1:17 p.m., the Director of Nursing (DON) stated the facility evaluates for adaptive/bed rails on admission and quarterly. She stated the facility does not obtain consent for the rails quarterly and does speak with the representatives or the resident quarterly. She reported that the assessment for Adaptive/Bed rails should portray the resident correctly. The DON reviewed the Adaptive Rail Screen, completed on 9/25/20, and confirmed that the screen did not portray Resident #51 correctly. The policy titled Adaptive Rail Guideline, effective 11/28/2017 and revised on 10/14/19, identified It is the standard of this center to ensure the safe use of adaptive rails as resident mobility aids and to prohibit the use of adaptive rails as restraints. The protocol of the policy included the following: - 1. Adaptive rails are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents; - 2. The adaptive rail will be monitored, evaluated, and reviewed for initial and ongoing needs by the clinical team; - 4. An assessment/evaluation/screen will be made to determine the resident's symptoms or reason for using adaptive rails; - 6. Pertinent information related to adaptive rail utilization should be documented in the resident's clinical record; - 7. Use of adaptive rails as an assistive device should be present in the resident-centered plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105566 If continuation sheet Page 4 of 20 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 105566 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Winter Haven 1120 Cypress Gardens Blvd Winter Haven, FL 33884 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that a physician order was written accurately for one resident (#23) out of five sampled residents for unnecessary medications. Residents Affected - Few Findings included: A review of the admission Record for Resident #23 revealed that the resident was initially admitted into the facility on [DATE] with a diagnosis of essential hypertension. A review of the Order Summary Report for 11/01/20 revealed the following: Verapamil HCL ER Tablet Extended Release 120 MG (milligram) - Give 3 tablet by mouth in the evening for htn (hypertension) SBP (systolic blood pressure) less than 100 or DBP (diastolic blood pressure) less than 50, Notify MD (medical doctor). A review of the Order Summary Report for 12/18/20 revealed the following: Verapamil HCL ER Tablet Extended Release 120 MG- Give 3 tablet by mouth in the evening for htn (hypertension) SBP (systolic blood pressure) less than 100 or DBP (diastolic blood pressure) less than 50, Notify MD. The physician orders did not indicate instructions to hold or administer the medication depending on the blood pressure. On 12/17/20 at 2:45 p.m., the Director of Nursing (DON) reported that the order was not correct. It should indicate to hold the medication. On 12/18/20 at 1:39 p.m., the Pharmacy Consultant reported that she feels like there was a typo with the order. She stated, I would imagine that it would say to hold the medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105566 If continuation sheet Page 5 of 20 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 105566 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Winter Haven 1120 Cypress Gardens Blvd Winter Haven, FL 33884 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interview the facility failed to accurately monitor the use of psychotropic medications for one resident (#79) out of five residents sampled for unnecessary medications. Findings included: Resident #79 was admitted on [DATE]. The admission Record included diagnoses of dementia in other diseases classified elsewhere without behavioral disturbance, moderate recurrent major depressive disorder, and unspecified psychosis not due to a substance or known physiological condition. The physician Order Summary Report, active as of 12/18/20, identified that Resident #79 has been administered the psychotropic medications Seroquel daily for psychosis, Sertraline daily for depression, and Melatonin at bedtime for insomnia. The December 2020 Medication Administration Record (MAR) instructed licensed personnel to monitor for types of behaviors with corresponding numerical indicators, as well as non-pharmaceutical interventions attempted, the outcome of interventions, and the side effects related to the use of Sertraline. The MAR also indicated that staff were to monitor and document behavior concerns using codes provided. Behavior code: - 0= no behavior, 1= fear/panic, 2= anger, 3= scream/yell, 4= danger/self/others, 5= delusions, 6= hallucinations, 7= sad/tearful, 8= emotion/act withdrawal, 9= insomnia, 10= other (describe). Interventions: - 1= Redirect, 2= 1 on 1, 3= ambulate, 4= activity, 5= return to room, 6= toilet, 7= give food, 8= give fluids, 9= change position, Encourage to rest, 11= back rub, 12= as needed (prn) medication (med). Outcomes: - I= Improved, S= Same, W= Worse. Side Effects: - 0= None, 1= Extrapyramidal Symptoms (EPS), 2= Tardive Dyskinesia, 3= Hypotension, 4= Increased Behavior. Every shift for Psychotropic Medication use. (List psychoactive medication (med)/s: Sertraline Hydrochloride (HCl)/melatonin/Seroquel. The December 2020 MAR indicated that during the Day shift on 12/5, 12/6, 12/12, and 12/13/20 the licensed personnel had documented NA for interventions, outcomes, and side effects related to the administration of the psychoactive medications. Also, on 12/10/20 staff identified the type of behaviors the resident exhibited, the non-pharmaceutical interventions, outcomes, and side effects with the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105566 If continuation sheet Page 6 of 20 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 105566 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Winter Haven 1120 Cypress Gardens Blvd Winter Haven, FL 33884 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few letter n, which was not an option in the instructions for monitoring the use of named medications. On 12/14/20, staff identified NA related to observed side effects despite the code, NA was not listed as an option for the monitoring of side effects. The monitoring of Resident #79's psychoactive medications during the Evening shift indicated staff members had used the code NA for interventions, outcome, and side effects on 12/1, 12/5, 12/6, 12/8, 12/12, and 12/13/20 despite NA was not a listed code for those areas. Staff members documented n for behaviors exhibited, interventions, outcomes, and side effects observed on 12/3, 12/4, 12/9, 12/10, 12/11, and 12/17/20. The staff also documented n for the Night shift for type of behaviors observed, non-pharmaceutical interventions, outcomes, and side effects exhibited by Resident #79 on 12/3, 12/7, 12/10, 12/11, and 12/16/20. The MAR indicated staff had documented NA has the interventions, outcomes, and the side effects that the resident exhibited on 12/1, 12/2/, 12/4-12/6, 12/8, 12/9, 12/12- 12/15, and 12/17/20. On 12/17/20 at 2:59 p.m., following an interview with the Director of Nursing (DON), she returned with Staff B, Licensed Practical Nurse (LPN). The LPN reported that he figured that if there were no symptoms he could document as NA. The DON informed him that documenting NA was not appropriate. On 12/18/20 at 1:39 p.m., an interview was conducted with the Pharmacy Consultant. When asked if NA was appropriate, she reviewed the December 2020 MAR of Resident #79 and stated a 0 would be better and would recommend documentation of 0 instead of NA for a scheduled medication. A review of Resident #79's active care plan identified the following focuses and interventions: - due to the use of anti-psychotic drug(s) the resident was at risk for drug-related side effects. The interventions related to the resident use of anti-psychotic medications included the instruction for nursing staff to monitor for effectiveness of medication and review for changes. (initiated on 5/4/20 and revised on 11/30/20) - had a potential for adverse consequences related to the use of a hypnotic. Two of the interventions related to the use of a hypnotic instructed nursing staff to monitor for side effects of hypnotic i.e.: headache, confusion, weakness, nausea, irritability, dry mouth, and report to physician (MD) as needed (prn) and to monitor for effectiveness of medication. (initiated on 9/8/20) - Resident had a diagnosis of depression and had the potential for adverse consequences of antidepressant medication. The interventions instructed staff to monitor for effectiveness of medication, monitor for side effects of medication i.e.: nausea, gastrointestinal problems, dizziness, fatigue, dry mouth, weight gain, and insomnia. (initiated on 12/9/20) - Had behavioral problems related to disruptive behavior at times, socially inappropriate behavior and verbally abusive at times and confabulates stories. No blood product related to religion. The interventions included instructions for nursing staff to administer and monitor the effectiveness and side effects of medications as ordered- see physician orders/MAR and to observe behavior episodes and attempt to determine underlying cause. (initiated on 9/6/18 and revised on 9/8/20) The December 2020 MAR did not include the side effects that the care plan instructed staff to monitor for; related to the administration of hypnotic and antidepressant medications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105566 If continuation sheet Page 7 of 20 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 105566 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Winter Haven 1120 Cypress Gardens Blvd Winter Haven, FL 33884 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 0758 Level of Harm - Minimal harm or potential for actual harm The policy titled, Administration of Drugs, effective October 2014 and revised in May 2017, instructed staff to observe the resident/patient for any changes during or following medication administration, notify physician of any adverse reactions. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105566 If continuation sheet Page 8 of 20 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 105566 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Winter Haven 1120 Cypress Gardens Blvd Winter Haven, FL 33884 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review the facility failed to ensure that the medication error rate was less than 5.00%. Twenty-nine medication administration opportunities were observed and fifteen errors were identified for one resident (#52) of five residents observed. These errors constituted a 51.72% medication error rate. Residents Affected - Some Findings included: On 12/15/20 at 11:08 a.m., an observation of medication administration with Staff C, Licensed Practical Nurse (LPN), was conducted with Resident #52. Staff C was observed administering the following medications: - Amlodipine 10 milligram (mg) tab orally - Bupropion Hydrobromide (HBr) Extended Release (XL) 300 mg tab orally - Ferrous Sulfate 325 mg tab orally - Metformin 500 mg tab orally - Gabapentin 300 mg capsule orally - Metoprolol Tartrate 25 mg tab orally - Myrbetriq Extended Release (ER) 50 mg tab orally - Furosemide 40 mg tab orally - Clearlax 30 milliliter (mL) orally - Levemir 100units(u)/mL - 40 units subcutaneous injection On 12/15/20, prior to the observation, Staff C was observed administering medications. The electronic December 2020 Medication Administration Record (MAR) indicated that resident profiles were colored red, identifying the medications were past their scheduled administration times, which the staff member confirmed. At 11:21 a.m., Staff C was asked why the medications were late and she stated, Lots of meds, lots of patients, and you still have to you know. She counted the red profiles and reported that she still had six residents to administer late medications too. A review of the December 2020 Medication Administration Record (MAR) indicated that the observed oral medications for Resident #52 were scheduled to be administered at 9:00 a.m. and the Levemir insulin had an 8:00 a.m. scheduled administration time. The observation identified that the medications administered orally to the resident were two hours late and the insulin injection was three hours past the scheduled administration time. A review of the December 2020 physician orders and MAR for Resident #52 revealed the following medication orders and scheduled administration times: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105566 If continuation sheet Page 9 of 20 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 105566 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Winter Haven 1120 Cypress Gardens Blvd Winter Haven, FL 33884 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 0759 Level of Harm - Minimal harm or potential for actual harm -- Accu-check before meals and at bedtime for Diabetes Mellitus (DM). Scheduled at 6:00 a.m., 11:30 a.m., 4:30 p.m., and 9:00 p.m.; -- Amlodipine 10 mg tab - give one tab by mouth (po) one time a day for Hypertension (HTN). Scheduled at 9:00 a.m.; Residents Affected - Some -- Bupropion HydroBromide (HBr) Extended Release (ER) 300 mg tab - give 300 mg po one time a day for depression. Scheduled at 9:00 a.m.; -- Cranberry capsule - Give 425 mg po one time a day for Chronic Cystitis. Scheduled at 10:00 a.m.; -- Ferrous Sulfate tablet 325 (65Fe) mg - Give one tablet po three times a day for anemia. Scheduled at 9:00 a.m., 1:00 p.m., and 5:00 p.m.; -- Gabapentin 300 mg capsule - give 300 mg po two times a day for neuropathy. Scheduled at 9:00 a.m. and 6:00 p.m.; -- GlycoLax powder (Polyethylene Glycol 3350) - Give 17gram po two times a day for constipation. Mix in 4-6 ounce (oz) of liquid. Scheduled at 9:00 a.m. and 5:00 p.m.; -- Lasix tablet 40 mg (Furosemide) - Give 40 mg po one time a day for edema. Scheduled at 9:00 a.m.; -- Levemir Solution (Insulin Determir) - Inject 40 unit subcutaneously two times a day for DM (Diabetes Mellitus). Scheduled at 8:00 a.m. and 8:00 p.m.; -- Lotensin tablet 40 mg (Benazepril HCl) - give one tablet po one time a day for HTN. Scheduled at 9:00 a.m.; -- Mirabegron ER tablet Extended Release 24 hour 50 mg - Give one tablet po one time a day for Bladder spasm. Scheduled at 9:00 a.m.; -- Novolog Solution (Insulin Aspart) - Inject as per sliding scale: if 151-200 = 2 units; 201-250 = 4 units; 251-300 = 6 units; 301-350 = 8 units; 351-400 = 10 units. If Blood sugar (BS) greater than 401 notify MD subcutaneously two times a day for DM. Scheduled at 11:00 a.m. and 8:30 p.m.; -- Potassium Chloride ER tablet Extended Release 10 milliequivalent (meq) - Give one tablet po one time a day for Congestive Heart Failure (CHF). Scheduled at 9:00 a.m.; -- Senna-Tabs tablet (Sennosides) - Give one tablet po two times a day for constipation. Scheduled at 9:00 a.m. and 6:00 p.m. A review of Staff C's documentation of administration times on 12/15/20 indicated that the staff member had administered additional oral medications for Resident #52 that were due and past due at the time of the observation, and had administered scheduled insulin outside of the sliding scale parameters: - Cranberry 425 mg capsule, due at 10:00 a.m. and according to Staff C's documentation was administered at 11:57 a.m., 1 hour and 57 minutes after the scheduled administration time and was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105566 If continuation sheet Page 10 of 20 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 105566 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Winter Haven 1120 Cypress Gardens Blvd Winter Haven, FL 33884 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 0759 included with the observation of medication administration; Level of Harm - Minimal harm or potential for actual harm - Lotensin 40 mg tab, due at 9:00 a.m., which the staff member informed writer and resident that she had to remove Losartan from the electronic Pyxis. The staff member documented that she had administered this medication at 11:23 a.m. with the observed medications. Residents Affected - Some - Potassium Chloride ER 10 milliequivalent (meq) orally, due at 9:00 a.m., not observed as given despite being past due during the observation. Staff C documented at 11:57 a.m. that this medication was given. - Senna Tab, no indicated dosage, due at 9:00 a.m. however was not observed as given despite being past the scheduled administration time during the observation. Staff C documented that at 11:57 a.m. this medication was administered. - Novolog insulin was due at 11:00 a.m. per a sliding scale dependent on the blood glucose level taken at that time and was not observed as administered during the observation, despite being within the scheduled administration time during the observation. The MAR indicated that Staff C had documented at 11:59 a.m., the administration of 6 units of Novolog, per the blood glucose level of X. The review of the MAR identified that staff members were to obtain a blood glucose level at 6:00 a.m., 11:30 a.m., 4:30 p.m., and 9:00 p.m., four times a day before meals and at bedtime. On 12/15/20 at 12:02 p.m., after the administration of Novolog, Staff C documented a blood glucose level of 198 and according to the sliding scale for Novolog, the staff member should have administered 2 units of Novolog not the 6 units documented. A review of Resident #52's progress notes, on 12/15/20 at 1:28 p.m., indicated the last note was written at 10:13 a.m. on 12/8/20 regarding the administration of the resident's Tramadol. The review of the resident's clinical record showed the last evaluation was completed on 12/8/20. The clinical record did not indicate Staff C had contacted the physician regarding administering medications outside of its scheduled time on 12/15/20. The Director of Nursing (DON) stated, on 12/18/20 at 10:32 a.m., that medications were to be given one hour before and one hour after the due time. The medication administration was described to the DON and she confirmed that the medication was late. When asked what her expectation was regarding the administration of late medications, she stated the nurse should be getting the unit manager and/or her and that they could have assisted the nurse with other duties so the nurse could concentrate on the administration. The DON confirmed that the nurse had given 6 units of Novolog after documenting an X for a blood glucose level and had documented an accu-check of 198 that did not agree with the scheduled administration at 11:30 a.m. of the Novolog Sliding Scale. She stated the amount of Novolog and the accu-check was not appropriate, as the sliding scale order was given for a reason. At 11:10 a.m. on 12/18/20, the DON indicated Resident #52 was not receiving Losartan, as expressed during the observation by the nurse. She indicated the resident was on Lotensin and the medication was available on the medication cart. The audit report received from the DON indicated that the medications that were administered within 40 minutes of the completion of the observation were also late and confirmed that the Novolog was administered outside of the sliding scale. The policy titled, Nursing - Administration of Drugs, effective October 2014 and revised in May 2017, described that Residents shall receive their medications on a timely basis and in accordance with our established policies. The Key Procedural Points of the policy indicated the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105566 If continuation sheet Page 11 of 20 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 105566 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Winter Haven 1120 Cypress Gardens Blvd Winter Haven, FL 33884 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some -- Prior to administration, review and confirm orders for each individual resident, observing the five rights of medication administration: right patient, right medication, right dose, right route, and right time. -- Obtain and record any vital signs needed prior to medication administration. The Reporting and Documentation of the policy indicated staff were to notify physician of any refusals, complaints, or problems related to the medication administration. An interview was conducted at 1:39 p.m. on 12/18/20 with the Pharmacy Consultant. She stated medications were due within one hour before and one hour after the scheduled time. She reported that staff should try to give medications at the same time every day and if the medications were late the doctor should be notified. The Pharmacy Consultant stated that the nurse should follow the physician orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105566 If continuation sheet Page 12 of 20 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 105566 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Winter Haven 1120 Cypress Gardens Blvd Winter Haven, FL 33884 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews the facility failed to ensure one resident (#52) out of five residents observed during the mandatory task of Medication Administration received medication within the parameters ordered by the physician. Residents Affected - Few Findings included: Resident #52 was admitted on [DATE]. The admission Record included diagnoses not limited to other specified diabetes mellitus with diabetic neuropathy and unspecified Type 2 diabetes mellitus with diabetic neuropathy. An observation at 11:08 a.m. on 12/15/20, during the mandatory task of Medication Administration revealed Resident #52 lying in bed and Staff C, Licensed Practical Nurse (LPN) asking Resident #52 if she wanted her scheduled laxative. Staff C was witnessed, at 11:08 a.m., administering by subcutaneous injection, Resident #52's 8:00 a.m. dose of 40 units of Levemir (Insulin Detemir), three hours past the scheduled time and two hours past the accepted nursing standard allowing for medication administration one hour before and one after the scheduled time. The resident's Levemir was scheduled at 8:00 a.m. and 8:00 p.m., two times a day. The staff member documented it was administered at 11:15 a.m. on 12/15/20. A review of the December 2020 physician orders and medication administration record (MAR) indicated that the LPN was to obtain, at 11:30 a.m., Resident #52's blood glucose level, this was not observed during the task of medication administration. A review of the MAR documentation indicated that at 12:02 p.m. the staff member had obtained a blood glucose level of 198. The MAR indicated the resident was to receive Novolog insulin (Insulin Aspart) per the following sliding scale: Novolog insulin: Inject as per sliding scale: if 151-200 = 2 units; 201-250 = 4 units; 251-300 = 6 units; 301-350 = 8 units; 351-400 = 10 units. If Blood sugar (BS) greater than 401 notify MD - subcutaneously two times a day for DM. Scheduled at 11:00 a.m. and 8:30 p.m. On 12/15/20 at 11:59 a.m., Staff C, LPN documented that 6 units of Novolog were administered, three times the amount the sliding scale indicated was to be administered for a blood glucose level of 198. The MAR did not identify the amount of insulin units were to be administered for a blood glucose level of X. On 12/18/20 at 10:32 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated that all medications should be administered one hour before and one hour after the scheduled time. She confirmed that the observed medications were late. When asked what her expectation was regarding the administration of late medications, she stated the nurse should be getting the unit manager and/or her and that they could have assisted the nurse with other duties so the nurse could concentrate on the administration. When informed of the medication administration observation and the review of the MAR she confirmed that Staff C had administered 6 units of Novolog for a blood glucose of X and that the accu-check of 198 was not appropriate as the sliding scale of Novolog was given for a reason and the 6 units were administered outside of the scale. On 12/18/20 at 1:39 p.m., an interview was conducted with the Pharmacy Consultant. The consultant (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105566 If continuation sheet Page 13 of 20 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 105566 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Winter Haven 1120 Cypress Gardens Blvd Winter Haven, FL 33884 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated medications are due an hour before and a hour after the scheduled time. She reported that staff should try to give medications at the same time every day and if the medications were late the doctor should be notified but would not expect anything significant for one med outside of the time frame. The Pharmacy Consultant stated that the nurse should be following the physician orders and in respect to the administration of Novolog she does not know if the number (blood glucose) was wrong or if the amount of the units were wrong. The policy titled, Nursing - Administration of Drugs, effective October 2014 and revised in May 2017, described that Residents shall receive their medications on a timely basis and in accordance with our established policies. The Key Procedural Points of the policy indicated the following: -- Prior to administration, review and confirm orders for each individual resident, observing the five rights of medication administration: right patient, right medication, right dose, right route, and right time. -- Obtain and record any vital signs needed prior to medication administration. The Reporting and Documentation of the policy indicated staff were to notify physician of any refusals, complaints, or problems related to the medication administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105566 If continuation sheet Page 14 of 20 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 105566 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Winter Haven 1120 Cypress Gardens Blvd Winter Haven, FL 33884 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure documentation was accurate on the November and December 2020 Medication Administration Records (MAR) for two residents (Resident #23 and #4) out of 28 sampled residents. Findings included: 1. A review of the admission Record for Resident #23 revealed that the resident was initially admitted into the facility on [DATE] with a primary diagnosis of metabolic encephalopathy. The active physician orders as of 11/01/2020 revealed the following order: Evaluate for respiratory symptoms. Notify MD/charge nurse if identified every 4 hours new or worsening malaise- Y (yes) or N (no), dizziness- Y or N, diarrhea- Y or N, sore throat- Y or N, Cough- Y or N, loss of taste/smell- Y or N. A review of the Medication Administration Record (MAR) for 11/01/20-11/30/20 revealed the following documentation for the order: NA (not applicable) was documented instead of Y or N according to the order on the following days in November: 1st, 2nd, and 5th through the 30th. The active physician orders as of 12/18/20 revealed the following order: Evaluate for respiratory symptoms. Notify MD/charge nurse if identified every 4 hours new or worsening malaise- Y (yes) or N (no), dizziness- Y or N, diarrhea- Y or N, sore throat- Y or N, Cough- Y or N, loss of taste/smell- Y or N. A review of the MAR for 12/01/20-12/31/20 revealed the following documentation of the order: NA (not applicable) was documented instead of Y or N according to the order on the following days in December: 1st -17th. A review of the progress notes for November and December 2020 revealed that the documentation was not reflected in the progress notes. The policy titled, Nursing-Charting/Documentation, with an effective date of October 2014 revealed the following: Services provided to the resident will be recorded in the resident's medical record. Documentation will be accurate and will include, but not limited to, response to treatment, change in condition, changes in treatment and physician notification. On 12/17/20 at 2:45 p.m., the Director of Nursing (DON) reported that Y or N should be documented on the MAR. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105566 If continuation sheet Page 15 of 20 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 105566 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Winter Haven 1120 Cypress Gardens Blvd Winter Haven, FL 33884 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 12/17/20 at 2:59 p.m., Staff B, Licensed Practical Nurse (LPN), reported that he figured that if there were no symptoms, he would just mark NA. Staff B came in with the DON and she informed him that documenting NA was not appropriate. 2. Review of the medical record for Resident #4 revealed that she was admitted to the facility on [DATE] and diagnoses included gastrostomy (a surgical opening made in the stomach for the placement of a feeding tube). The active December 2020 physician orders revealed that the resident was not receiving any nutrition, hydration, or medications via the feeding tube. The active orders revealed that she was on a completely by mouth diet and that all her medications were to be administered by mouth. The active orders revealed two orders related to tube flushing: 1. Flush feeding tube with 30-50 ml of water before and after medications; flush with 5 ml (milliliters) of water between each medication every shift, 2. Flush feeding tube manually with 100ml of water one time a day. A progress note dated 12/02/20 revealed that nutrition via the feeding tube was discontinued due to transition to by mouth diet only and that the flush order would be for a manual flush with 100 ml of water daily. On 12/17/20 the medication administration record (MAR) for December 2020 was reviewed and revealed the order for manual feeding tube flush with 100ml of water one time a day scheduled for 8:00 a.m., order date 12/02/20, and signed off as administered 12/03/20-12/17/20. The MAR also revealed an order for flushing the feeding tube with 30-50 ml of water before and after medications and with 5ml of water between each medication every shift. The administration record for that order was signed off as administered 12/07/20-12/17/20. An interview was conducted with Staff A, Registered Nurse (RN) on 12/17/20 at 12:28 p.m. She confirmed that she was the assigned nurse for Resident #4 and confirmed that the resident did not receive any nutrition, hydration, or medications through the feeding tube. She stated that the orders for tube flushing were to perform every shift with 100 ml of water. Staff A was asked to review the MAR for December 2020 and confirmed that her initials were recorded for the following administrations on 12/17/20: flush feeding tube manually with 100 ml of water one time a day; flush feeding tube with 30-60 ml of water before and after medications, flush with 5ml of water between each medication every shift. She confirmed that her initials were also present for other dates for these order sets. Staff A confirmed that there should not be an order for flushing between medications because the resident did not take any medications via the feeding tube and stated that the flush should not be ordered that way. Regarding why she had signed off as performing that order on 12/17/20 and other dates in December she said, .didn't take time to read the order. She confirmed that it was the responsibility of the nurse performing administration to ready orders before administering and to act when noting an error with any order. She said, I'm sorry I did that .I'm going to have it changed right now. An interview was conducted with the DON on 12/18/20 at 1:55 p.m. She confirmed that it was her expectation that a nurse should always read an order before administering treatment or medication, and should never document administration of anything without first reading the order. She stated it was her expectation that if a nurse discovered a problem with an order they should stop and immediately report to the DON and the ordering physician. She stated there had never been a need in the facility to audit orders and said, My expectation is a nurse should know they need to read and come to me with problems. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105566 If continuation sheet Page 16 of 20 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 105566 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Winter Haven 1120 Cypress Gardens Blvd Winter Haven, FL 33884 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and review of the policy and procedure, it was determined that the faciltiy did not ensure an effective Quality Assurance and Performance Improvement (QAPI) plan was implemented to monitor corrective action to ensure that adaptive rail assessments were accurate for three residents (#3, #5, #6) of four residents reviewed. Findings included; Review of the facilty policy titled, QAPI - Nursing, Social Services, Risk Management, with an effective date of February 20, 2018 and a revision date of May 2018, revealed : Policy: Each center must develop, implement, and maintain an effective comprehensive date driven Quality Assurance and Performance Improvement (QAPI) program that focuses on indicators of the outcomes of care and quality of life. QAPI identifies opportunities for improvement, addresses gaps in systems and involves performance improvement plans with monitoring of interventions. Procedure: 5. The center must take action aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained. 9. The QAPI committee will develop, document and implement appropriate plans of action to correct identified quality deficiencies. On 3/3/21 at 3: 50 p.m., an interview was conducted with the Administrator, the Regional Director of Clinical Services and Staff A, the Registered Nurse (RN) who conducted adaptive rail audits. They stated that an initial whole house audit was completed on 1/12/21 to ensure that all adaptive rail evaluations were correct Audits of adaptive rail evaluations were conducted for new admissions on 1/18/21, 1/22/21, 1/26 21, 2/1/21, 2/3/21, 2/5/21, 2/8/21, 2/12/21, 2/15/21, 2/18/21, 2/19/21, 2/23/21, 2/24/21, 2/26/21 and 3/1/21 by Staff A. Three new admissions (#3, #5 and #6) were reviewed for accuracy of the assessments for adaptive rails. On 3/3/21 at 2: 55 p.m., Resident #3 and #6 were receiving care in their room and the Director of Nursing (DON) and Assistant Director of Nursing (ADON) had just exited the room. Both the DON and ADON stated that both the residents utilized the adaptive rails. Review of the record for Resident #3 revealed that he was admitted to the facility on [DATE] with diagnoses that included metabolic Encephalopathy, Parkinson's Disease, unspecified dementia with behavioral disturbance, bipolar disorder, major depressive disorder, anxiety disorder and heart failure. Physician orders for February and March 2021 revealed the following medications, ordered on 2/26/21: Furosemide Tablet 40 mg (milligram) , Give 1 tablet by mouth two times a day for Congestive Heart Failure, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105566 If continuation sheet Page 17 of 20 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 105566 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Winter Haven 1120 Cypress Gardens Blvd Winter Haven, FL 33884 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 0867 Clonazepam tablet 1 mg, Give 1 tablet by mouth at bedtime for anxiety, Level of Harm - Minimal harm or potential for actual harm Venlafaxine HCI tablet 75 mg, 1 tablet by mouth at bed time for anxiety, Venlafaxine HCI tablet 75 mg, Give 1 tablet by mouth at bed time for depression, Residents Affected - Few Lamotrigine Tablet 25 mg, Give 3 tablets by mouth in the evening for Bipolar, Olanzapine tablet 2.5 mg, Give 1 tablet by mouth two times a day for Bipolar. Review of the February and March 2021 Physician Order Summary for Resident #3 revealed that he received these medications daily. Review of the Adaptive Rail Screen for Resident #3, dated 2/26/21, revealed the use of adaptive rail(s) was being considered due to Resident requested for Safety/ Security. Resident's need to use adaptive rail(s) was identified as having balance deficit, requested rails, history of falling out of bed. Review of the Adaptive Rail Screen for Resident #3, dated 2/26/21, revealed under Section B Additional Comments and Risk Factors: 18. Taking medications that require increased safety measures ( i.e., diuretics, psychotropics, etc.), that the response to this question was recorded as No. The routine daily use of Lamotrigine, Olanzapine, Clonazepam, Venlafaxine and Furosemide was not identified on the Adaptive Rail Screen. Adaptive rails were recommended due to Resident request. The recommendation was for adaptive assist bar on both sides, rails are recommended at all times when resident is in bed, risks and benefits of rail use and alternatives to rails were documented as discussed with the resident. Review of the record for Resident #5 revealed that he was admitted to the facility on [DATE] with diagnoses that included Encephalopathy, acute on chronic combined systolic (Congestive) and diastolic (Congestive) heart failure, dementia in other diseases classified elsewhere without behavioral disturbance, bipolar disorder, major depressive disorder, and insomnia. Review of the February and March 2021 Physician Order Summary for Resident #5 revealed that the following medications were ordered 2/8/21 and were ongoing orders: Escitalopram Oxalate 10 mg, Give 1 tablet by mouth one time a day for Major Depressive, Quetiapine Fumarate tablet 50 mg, Give 1 tablet by mouth three times a day for Bipolar Disorder, Trazadone HCI tablet 150 mg, Give 1 tablet by mouth at bedtime for Major Depressive. Review of a Adaptive Rail Screen for Resident #5, dated 2/8/21, revealed that adaptive rails were being considered due to family requested for safety/security, identified needs for adaptive rail use were documented as balance deficit, requested rails, history of rolling gout of bed, and history of sliding out of bed. Under Section B Additional Comments and Risk Factors: 18. Taking medications that require increased safety measures ( i.e., diuretics, psychotropics, etc.), that the response to this question was recorded as No. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105566 If continuation sheet Page 18 of 20 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 105566 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Winter Haven 1120 Cypress Gardens Blvd Winter Haven, FL 33884 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The routine daily use of Escitalopram Oxalate, Quetiapine Fumarate and Trazadone was not identified on the Adaptive Rail Screen. Recommendations for adaptive rails stated adaptive rails are recommended at this time due to Resident Request, recommended type was adaptive assist bar on both sides,. Rails were recommended at all times when resident is in bed and the risks and benefits of rail use were discussed with the resident and family. Review of the record for Resident #6 revealed that he was admitted to the facility on [DATE] with diagnoses that included heart failure, major depressive disorder, and anxiety disorder. Review of the February and March 2021 Physician Order Summary revealed that Resident #6 was prescribed the following medications as of 2/25/21: Lasix tablet 20 mg ( Furosemide), Give 1 tablet by mouth one time a day for Edema, Quetiapine Fumarate tablet 50 mg, Give 1 tablet by mouth in the evening for Bipolar Disorder, Venlafaxine HCI ER tablet extended release 24 hour 37.5 mg, Give 1 tablet by mouth one time a day for Major Depression. Review of the Adaptive Rail Screen, dated 2/25/21 for Resident #6 revealed the use of adaptive rails was being considered due to Resident requested for safety/security. Identified needs for the use of adaptive rails were weakness, balance deficit, requested rails, and a history of sliding out of bed. Under Section B Additional Comments and Risk Factors: 18. Taking medications that require increased safety measures ( i.e., diuretics, psychotropics, etc.), that the response to this question was recorded as No. The routine daily use of Lasix, Quetiapine Fumarate and Venlafaxine was not identified on the Adaptive Rail Screen. Recommendations were for adaptive rails due to resident request. adaptive assist bar on both sides, rails are recommended at all times when resident is in bed and risks and benefits of rail use and alternatives to rails have been discussed with the resident. At approximately 1: 30 p.m. on 3/3/21, the DON stated that the use of the psychotropic medications and diuretic medications should be assessed and documented on the adaptive rail screens. Review of the Ongoing Monitoring revealed, the facility DCS [Director of Clinical Services]/ Designee will conduct weekly quality review ensuring that Adaptive Rail Evaluations have been completed on residents to reflect accurate assessment of their use of adaptive/ bed rail x 3 months. The findings of these reviews will be reported in the next Risk Management QA Committee Meeting until Committee determines substantial compliance has been met and recommends quarterly monitoring by the Regional Director of Clinical Services when completing their systems review. A Quality Monitoring audit was completed on 3/1/21 of the adaptive rail screen for Resident #3 by Staff A, RN. The Quality Indicator for: All sections on the Adaptive Rail Evaluations are completed to reflect resident's current abilities, was answered as, Yes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105566 If continuation sheet Page 19 of 20 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 105566 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Winter Haven 1120 Cypress Gardens Blvd Winter Haven, FL 33884 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A Quality Monitoring audit was completed on 2/12/21 of the adaptive rail screen for Resident #5 by Staff A. The Quality Indicator for: All sections on the Adaptive Rail Evaluations are completed to reflect resident's current abilities, was answered as, Yes. A Quality Monitoring audit was completed on 2/26/20 of the adaptive rail screen for Resident #6 by Staff A. The Quality Indicator for: All sections on the Adaptive Rail Evaluations are completed to reflect resident's current abilities, was answered as Yes. An interview was conducted with Staff A, the Administrator and the Regional Director of Clinical Services on 3/3/21 at 3: 50 p.m. Staff A stated that when she did the initial whole house audit for the adaptive rail screens on 1/12/21 she ensured that all adaptive rail evaluations were correct. When she conducted the audits of the adaptive rail evaluations for the new admissions; she did not validate the evaluations, but relied on the nurse who did the evaluation to have done it correctly. She stated that instead of checking that it was done correctly, she relied on the person who did it to have done it correctly. The Regional Director of Clinical Services stated that, We will have her ( Staff A) go fix the forms now and we will redo all the new admits now. On 3/3/21 at 4: 30 p.m. the Regional Director of Clinical Services stated that Staff A not checking the audits was an oversight. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105566 If continuation sheet Page 20 of 20