Health inspection·March 10, 2022

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few they pass and set up meal trays. Staff B revealed Resident #42 was able to self-feed and she sets up the tray and leaves. She revealed Resident #42 should be supervised when eating. She confirmed he spills food on himself from self-eating. She will see food on his shirt when she picks up the tray at a later time. Staff B interpreted ADL activities for Supervision meant staff must stay in the room with the resident when eating and watch his eating with some cueing if need, and One plus Person physical assist, meant that staff are to stay in the room with the resident and assist with eating/feeding assistance should the resident require it. During the continued interview Staff B, CNA again revealed she believed Resident #42 required supervision, and then confirmed she should probably be in the room with the resident when he eats his meal. Staff B revealed it was hard to stay in the rooms and provide supervision only; when other residents in the halls and unit need to be served and set up with their meals. She confirmed there are not enough staff to appropriately set up, serve and supervise all residents on the unit. She explained the staff all help out each other the best they can. Review of Resident #42's admission Record revealed he was admitted to the facility on [DATE] with diagnoses to include: dementia, GERD (gastroesophageal reflux disease), hyperlipemia, DMII (Diabetes Mellitus Type II), long term use of insulin, and dysphagia. Review of the 5 day Minimum Data Assessment (MDS), dated [DATE], revealed in Section C - Cognition Patterns Resident #42's Brief Interview for Mental Status score was a 7 of 15, which indicated the resident would not be able to speak with relation to his medical needs. Section G - Functional Status revealed the Activities of Daily Living for Eating required Supervision with one person physical assist. Review of the current Order Summary Report, dated for the month of 3/2022 revealed physician orders to include: *CONCHO (consistent Carbohydrate) diet, mechanical soft texture, Thin fluid consistency, start date 2/16/22, *ST (speech therapy) clarification order: UPOC (updated plan of care) 4 times per week for 30 days for Dysphagia Tx (treatment), dev/imp (develop/implementation) of safe swallow strategies, therapeutic trials, dietary analysis, pt/caregiver (patient) ed/training (education), discharge planning, start date of 3/8/2022. Review of the following assessments revealed: - 1/10/2022 Nutritional assessment revealed: Resident confused at times and with poor PO (oral) intake possibly related to confused state, and to monitor. - 1/17/2022 Standard of Care meeting revealed: Nothing related to ADL (Eating) - 2/4/2022 Monthly Nurse Summary revealed: Eating habits are usually with poor appetite. Was not checked if feeds self, or feeds with assistance. - 2/17/2022 SOC (Standard of Care) meeting/evaluation revealed: Nothing related to ADL (Eating) - 2/24/2022 SOC meeting/evaluation revealed: Nothing related to ADL (Eating) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105566 If continuation sheet Page 2 of 11 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 03/10/2022 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 0677 - 3/2/2022 SOC meeting/evaluation revealed: Nothing related to ADL (Eating) Level of Harm - Minimal harm or potential for actual harm - 3/4/2022 Monthly Nursing Summary revealed: Usually good eating habits, but did not specify if resident feeds self or feeds with assistance. Residents Affected - Few Review of the CNA ADL flow sheet for the months of 2/2022 and 3/2022 revealed the resident received the following for Eating activity: a. 2/24/2022 - 2/27/2022 all three meals Independent; b. 2/28/2022 breakfast Limited Assist; lunch and dinner Independent; c. 3/1/2022 - 3/2/2022 all three meals Independent; d. 3/3/2022 - breakfast and lunch Extensive Assist and dinner Independent; e. 3/4/2022 - breakfast and lunch Independent and dinner Supervision; f. 3/5/2022 - Independent all meals; g. 3/6/2022 - 3/8/2022 Independent with all meals. Review of the current care plan, revised on 1/20/22 and with the next review date of 4/20/2022, documented a Focus as: Resident's ADL needs include bed mobility; transfers; locomotion/walking; dressing; eating; toileting; personal hygiene; bathing. The goal was the resident will receive the amount of necessary ADL assistance to improve/maintain quality of life. The interventions included: The resident is not able to feed self all or some of the meal and needs staff to feed him. Staff will need to remain with the resident for the entire meal, initiated on 1/5/22. On 3/9/2022 at 10:10 a.m. an interview with Staff A, MDS Coordinator and the Regional MDS Coordinator confirmed Resident #42 had been marked and observed at least one day during their assessment, for the need for supervision with one person assist in relation to eating. They both confirmed the care plans indicated the resident does require eating supervision and staff was to be in the room when he eats. They were not aware that staff had been placing the meal tray in the room, setting up the meal and then leaving. On 3/9/2022 at 10:30 a.m. an interview with the Staff J, Speech Therapist revealed she has had Resident #42 on her case load for over thirty days, and the reason for the new order on 3/8/2022 was because they have to reorder every thirty days. She has been observing him for aspirations during eating and does not look at him for the ability to self-feed and that was more of physical and occupation therapy. She revealed she has not seen him spilling food on his shirt but she does not see him or assess him every day, and only has him on case load four times a week. On 3/10/2022 at 9:50 a.m. an interview with the Therapy/Rehab Director revealed Resident #42 was currently being seen by PT/OT (physical therapy/occupational therapy) and she was aware Resident #42 does eat on his own but requires some staff supervision in his room, when he eats. She was not aware, prior to yesterday (3/9/2022), that staff were just dropping off his meal tray and then leaving the room until coming back to pick up the tray. She did confirm he would benefit more with eating activities if staff were in the room and supervised him during the entire meal service. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105566 If continuation sheet Page 3 of 11 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 03/10/2022 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 3/10/2022 at 11:40 a.m. an interview with the Director of Nursing confirmed Resident #42 had been assessed and care planned to have staff supervision with one person assist, while he eats in his room, for each meal. She revealed that meant staff are to bring in the meal tray, set the meal up for the resident, and then stay in the room as he eats and provide either cueing and/or hands on assist should he have the need. She confirmed staff should not have just dropped off the meal tray and then leave the room without any continued eating supervision. Further interview with the Director of Nursing revealed the facility did not have any type of Activities of Daily Living policy and procedure. She revealed there were no policies and procedures with relation to eating assistance. Event ID: Facility ID: 105566 If continuation sheet Page 4 of 11 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 03/10/2022 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure a medication administration error rate of less than 5%. A total of 36 administration opportunities were observed with 10 medication errors for three residents (#57, #443, and #49) of five residents observed for medication administration, resulting in a medication administration error rate of 38.46%. Residents Affected - Some Findings included: 1. A review of Resident #57's admission Record revealed Resident #57 was admitted to the facility on [DATE] with a diagnosis of constipation. A review of Resident #57's physician's orders revealed an order dated 09/29/2021 for Senokot tablet, give one tablet by mouth one time a day for constipation. An observation of medication administration for Resident #57 was conducted on 03/09/2022 at 8:20 a.m. with Staff E, Registered Nurse (RN). Staff E prepared thirteen medications for administration to Resident #57, including Senokot 8.6 milligrams (mg) by mouth. After preparing the medications, Staff E, RN entered Resident #57's room and administered the thirteen medications to Resident #57. 2. A review of Resident #443's admission Record revealed Resident #443 was admitted to the facility on [DATE] with diagnoses of heart failure and stage 4 chronic kidney disease. A review of Resident #443's physician's orders revealed an order dated 03/05/2022 for Magnesium tablet, give one tablet by mouth one time a day for hypomagnesemia. An observation of medication administration for Resident #443 was conducted on 03/09/2022 at 8:45 a.m. with Staff D, RN. Staff D, RN prepared Magnesium 400 mg by mouth for administration to Resident #443. After preparing the medications, Staff D, RN entered Resident #443's room and administered the thirteen medications to Resident #443. 3. A review of Resident #49's admission Record revealed Resident #49 was admitted to the facility on [DATE] with diagnoses of end stage renal disease, epilepsy, and hypertension. A review of Resident #49's physician's orders revealed the following orders: - An order dated 01/12/2022 for Hydrochlorothiazide (HCTZ) 25 mg by mouth one time a day for hypertension at 08:00 AM. - An order dated 01/12/2022 for Lisinopril 40 mg by mouth one time a day for hypertension at 08:00 AM. - An order dated 01/12/2022 for Minoxidil 2.5 mg by mouth one time a day for hypertension at 08:00 AM. - An order dated 01/12/2022 for Calcium Carbonate tablet, one tablet by mouth two times a day for indigestion at 08:00 AM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105566 If continuation sheet Page 5 of 11 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 03/10/2022 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 - An order dated 02/14/2022 for Colace 100 mg by mouth two times a day for constipation at 09:00 AM and 06:00 PM. - An order dated 01/12/2022 for Keppra 2000 mg by mouth two times a day for seizures at 08:00 AM and 05:00 PM. Residents Affected - Some - An order dated 01/12/2022 for Labetalol Hydrochloride (HCl) 300 mg by mouth every 12 hours for hypertension at 08:00 AM and 08:00 PM. - An order dated 03/07/2022 for Renvela 2400 mg by mouth two times daily every Tuesday, Thursday, and Saturday for chronic kidney disease at 08:00 AM and 05:00 PM. An observation of medication administration for Resident #49 was conducted on 03/09/2022 at 9:12 a.m. with Staff C, RN. Staff C, RN prepared the following medications for administration to Resident #49: - Hydrochlorothiazide (HCTZ) 25 mg by mouth. - Lisinopril 40 mg by mouth. - Minoxidil 2.5 mg by mouth. - Calcium 600 mg plus Vitamin D by mouth. - Colace 100 mg by mouth. - Keppra 2000 mg by mouth. - Labetalol HCl 300 mg by mouth. - Renvela 2400 mg by mouth. After preparing the medications, Staff C, RN entered Resident #49's room to administer the medications. During the observation, Resident #49 asked Staff C, RN what medications he was taking and stated that he did not recognize one of the medications. Staff C, RN explained to Resident #49 that it was his calcium pill. Resident #49 responded to Staff C, RN by stating he did not remember being prescribed a calcium pill, but he would take it. Staff C, RN assured Resident #49 the medications were correct and Resident #49 was administered the medications at 9:38 a.m. After the medications were administered, Resident #49 told Staff C, RN he regularly took Tums (Calcium Carbonate) every day due to having indigestion. Staff C, RN told Resident #49 he did not have an order for Tums and the physician would be in the facility later in the day to review his medications. An interview was conducted on 03/09/2022 at 9:45 a.m. with Staff C, RN and the Regional Director of Clinical Services (RDCS). Staff C, RN reviewed Resident #49's physician's orders and pulled out the bottle of Calcium 600 mg plus Vitamin D from the medication cart. Staff C, RN explained the medication order did not have a dosage documented in it, but the dosage the facility stocks is 600 mg and that's what they use. Staff C, RN did not realize the wrong medication was administered. The RDCS stated Calcium Carbonate should have been administered instead of Calcium 600 mg plus Vitamin D to Resident #49. Staff C, RN was not able to state how long they had to administer medications from the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105566 If continuation sheet Page 6 of 11 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 03/10/2022 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 ordered administration time. The RDCS stated she thought nursing staff had two hours from the ordered time to pass the medications but she would need to check the facility policy. An interview was conducted on 03/09/2022 at 10:00 a.m. with Staff E, RN. Staff E, RN reviewed the physician's orders for Resident #57 and pulled a bottle of Senokot 8.6 mg from the medication cart. Staff E, RN compared the physician's order with the medication bottle and addressed the physician's order for Senokot did not have a dosage documented in the order. Staff E, RN stated the medication dosage should be verified by the nurse before administering a medication. If a medication order did not have a dosage associated with it, the order would be clarified with the resident's physician. Staff E, RN stated medications need to be administered within an hour before to an hour after the physician's ordered administration time and the resident's physician would need to be notified if the medication was administered after the ordered time. An interview was conducted on 03/09/2022 at 10:05 a.m. with Staff D, RN. Staff D, RN reviewed the physician's orders for Resident #443 and pulled a bottle of Magnesium 400 mg from the medication cart. Staff D, RN compared the physician's order with the medication bottle and addressed the physician's order for Magnesium did not have a dosage documented in the order and stated the facility only stocked Magnesium 400 mg so that's what they administered. Staff D, RN also stated if a medication order did not have a dosage associated with it, the order would be clarified with the resident's physician. Staff D, RN stated medications need to be administered within an hour before to almost an hour after the physician's ordered administration time. An interview was conducted on 03/10/2022 at 9:43 a.m. with the facility's Director of Nursing (DON). The DON stated nursing staff should be following the five rights of medication administration when administering medications to residents, including the right dose, the right resident, the right time, the right medication, and the right route. The five rights should be verified for each medication that is pulled from the medication cart. If a physician's order does not contain all of the required information, the medication should not be administered until the order could be clarified with the resident's physician. If a house stocked medication had a dosage then it should be included in the physician's order. The DON stated nursing staff have from an hour before to an hour after the physician's ordered medication time to administer a medication and if the medication is to be administered late then the resident's physician needed to be notified before the medications were administered. A telephone interview was conducted on 03/10/2022 at 10:46 a.m. with the facility's Consultant Pharmacist (CP). The CP stated she visited the facility on a monthly basis and conducted medication regimen reviews monthly for all residents at the facility. Medication orders are reviewed to ensure the right medication, the right dose, the right indication for use, and the right monitoring are in place for each medication ordered. Audits of medication administration are conducted on a quarterly basis with the nursing team to ensure nursing staff are using the five rights of medication administration during the task. The CP stated she would expect nursing staff to clarify a physician's order if they noticed an irregularity with it and that medication orders should include the strength of the medication if it is visible on the bottle. The CP also stated she would expect nursing staff to administer medications within the ordered timeframes. A review of the facility policy titled, General Dose Preparation and Medication Administration, last revised on 01/01/2022, revealed under the section titled Procedure that facility staff should verify the medication name and dose are correct when compared to the medication order on the medication administration record. The policy also revealed facility staff should verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105566 If continuation sheet Page 7 of 11 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 03/10/2022 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 correct rate, at the correct time, for the correct resident, as set forth in the facility's medication administration schedule. 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: 105566 If continuation sheet Page 8 of 11 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 03/10/2022 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and policy review, the facility did not ensure one resident's (#392) food preferences were honored out of five sampled residents. Findings included: An observation and interview was conducted on 03/07/2022 at 9:27 a.m. with Resident #392 and the resident's family member. The resident expressed she was a diabetic, she received insulin on a sliding scale, and stated she received a lot of regular sugared style foods since arriving to the facility. The family member also expressed her concern as she stated after [Resident #392] arrived at the facility they met with the CDM (Certified Dietary Manager) and asked that [Resident #392] only receive sugar free [gelatin dessert], sugar free pudding and other sugar free desserts. She also noted that she does not receive her NAS (No Sugar Added) house shakes. Almost a month later she has yet to receive her requested food items; even after several conversations with dietary staff. Resident #392 stated she dislikes oatmeal and orange juice and clearly stated that to the CDM (Certified Dietary Manager), when she arrived at the facility. Resident #392's breakfast tray revealed a cup of unopened orange juice and a bowl of oatmeal with a lid with the word Fortified hand-written on the lid. At this time, Resident #392 confirmed her diet was a diabetic diet. On 03/08/2022 at 7:30 a.m., Resident #392 had just received her breakfast tray. An observation revealed the resident received orange juice, and fortified oatmeal; both of which the resident stated are dislikes. Her breakfast tray ticket showed Homemade Muffin, Scrambled Eggs, Juice of Choice and Fortified Oatmeal. The tray ticket did not show dislikes. She stated the CDM came in last night (03/07/2022) and spoke to her and her [family member]. She (CDM) told them she would document her preferences, regarding her dislikes and also change to all sugar free desserts. On 03/08/2022 at 11:46 a.m. an interview and observation with Resident #392 was conducted. Resident #392 was eating her lunch and pointed out there was no sugar free dessert, sugar free [gelatin dessert] or sugar free pudding on her tray as requested. On 03/09/2022 at 7:36 a.m. an interview and observation were conducted of Resident #392, who just received her breakfast tray. On the tray was a cup of unopened orange juice and a bowl of oatmeal labeled Fortified, handwritten on the lid. Resident #392 again stated that she received items she does not like and has requested several times for them to be removed. On 03/09/2022 at 2:00 p.m. in an interview with the CDM she stated if a resident dislikes a specific food (fortified menu item) then they would offer a magic cup and/or mighty shake. A review of the Clinical Physician Orders form, printed from the electronic medical record (EMR), showed an admission date of 2/10/22 and the following orders related to Resident 392's diet: *Order for [NAME] (Consistent Carbohydrate) diet, Mechanical Soft texture, Thin Fluids consistency - Start Date 03/08/2022, and Revision Date 03/08/2022; *Order for [NAME] diet DYS 2(Dysphagia Diet 2),Thin Fluids consistency - Start Date 02/18/2022, Revision Date 02/18/2022, End Date 3/08/2022. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105566 If continuation sheet Page 9 of 11 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 03/10/2022 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 0803 A review of the progress notes showed: Level of Harm - Minimal harm or potential for actual harm *02/21/2022 at 14:27 (2:47 p.m.) Writer (CDM) contacted [family member] related to diet restrictions questions. [Family member] had questions related to Controlled Carb Diet, requested [Resident#392] to get SF (Sugar Free) [gelatin dessert] and SF Pudding at times. Will honor her request and continue to monitor. Residents Affected - Few *02/23/2022 at 13:07 (1:07 p.m.) Added SF-House shake w/lunch (with lunch) and dinner and Fortified Foods w/meal for additional needs. *03/07/2022 at 19:35 (7:35 p.m.) Writer visited resident and [family member] today in reference to [family member] had concerns related to [Resident #392's] diabetic diet. Writer spoke with [family member] in February related to same concerns. [Family member] expressed she would like [Resident #392] to have sugar free desserts with Lunch and Dinner meals, [Resident #392] agreed that she would like only sugar free desserts. Dietary will honor her requested and provide SF pudding/gelatin. Writer updated food preferences with [Resident #392] also. Will continue to monitor. On 03/10/2022 at 7:30 a.m., during an interview with Resident #392 and her family member the breakfast tray ticket was observed on the tray and showed the resident was to receive 4 ounces of juice of choice 6 ounces of hot cereal. The observation revealed Resident #392 received a container of orange juice and a bowl of oatmeal. The tray ticket did not show dislikes. The family member expressed concern because she and the resident were told by the CDM the evening before that [Resident 392's] preferences would be updated. On 03/10/2022 at 9:45 a.m. a review of the medical record revealed it was silent related to food preferences of Resident #392. A review of the care plan for Resident #392 revealed a Focus as potential for altered nutrition R/T (related to) increased nutrient needs; P-C malnutrition (phenotypic criteria which are baseline measures that are used to diagnose, malnutrition), initiated on 02/15/2022. The goal was documented as: Will maintain adequate diet intake to achieve stable weight. Interventions included: Monitor labs as ordered, Serve diet as ordered, Weigh per protocol. The care plan was silent related to food preferences. 03/10/2022 at 11:00 a.m. an interview with the CDM was conducted. The CDM confirmed she does not put food preferences in the electronic medical record (EMR). The food preference information was completed within a few days of the resident arriving to the facility. A hard copy was kept in the CDM's office and information was documented in [Meal Tracking Software]. It was a program that generated the resident profile and tray tickets for all meals. A review of the facility policy titled, Obtaining Food Preferences Guidelines, dated June 16, 2020, revealed: Purpose: What we eat is determined by our personal preferences. Honoring food preferences is important to maximize meal intake. Procedure: Food preferences will be obtained as soon after admission as possible. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105566 If continuation sheet Page 10 of 11 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 03/10/2022 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 0803 Level of Harm - Minimal harm or potential for actual harm It is recommended that documentation be included in the EMR that preferences were either obtained or updated. The Food Preference Assessment may be printed from Meal tracker as needed to demonstrate the preferences entered. The History can be assessed to be determined when the information was entered. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105566 If continuation sheet Page 11 of 11