Health inspection·June 20, 2024

F 0550 The facility did not have a policy related to this citation for review. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105566 If continuation sheet Page 2 of 21 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 06/20/2024 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to report an allegation of abuse within the required timeframe for one resident (#81) out of three residents sampled. Findings Include: An interview was conducted on 06/20/2024 at 1:00 p.m., with Staff L, Risk Manager (RM), and the Nursing Home Administrator (NHA). Staff L, reported Staff M, Registered Nurse (RN) Unit Manager, notified her on 6/12/ 2023 at 11:30 p.m. that Resident #81's family member had called around 10:30 p.m., and reported Resident #81 informed her (the family member) the assigned Certified Nursing Assistant, (CNA) was yelling and throwing things around in his room. The family member reported the CNA jumped on Resident #81's back and stomped on him. Staff L stated she was not able to hear everything Staff M, RN was saying to her over the phone due to poor phone reception. She said she told Staff M to file a grievance and she would follow-up on it in the morning. The RM stated, the next day when she returned to work, she called Resident #81's family member to follow-up regarding what was reported to Staff M, RN the night before. Staff L stated the family member reported Resident #81 had called to report his assigned CNA was in his room yelling at him, throwing things around in his room, and the CNA had jumped on his back and stomped on him. Staff L, RM said she interviewed Resident #81 who reported to her his CNA was putting oil on his back. The RM stated Resident #81 said he wanted the CNA to rub his back a little harder and that is when the CNA began to punch him on his back and on his head. The NHA stated, I know what you are thinking about the timeframe the report was filed. She stated she spoke with the RM and the Unit Manager about the phone conversation they had regarding Resident #81. The NHA stated she told both the RM and Staff M, RN when a phone call is made regarding an allegation of abuse, the Unit Manager needs to start the conversation by saying, I'm calling about an allegation of abuse, just in case the phone call drops. In addition, the Risk Manager should have called Staff M, RN back so the phone conversation could have been clarified. During an interview on 06/20/2024 at 2:35 p.m., with Staff M, RN Unit Manager she stated she made a phone call to Staff L, Risk Manager on 6/12/2024 around 11:30 p.m. She said she reported to Staff L, RM that Resident # 81's family member had called the facility to report an allegation of abuse. She stated the resident's family member told her Resident #81 called to report the CNA was in his room yelling at him and throwing things around in his room. She said the family member reported Resident #81 said the CNA hit him on his back while she was putting oil on him. Staff M stated she knew this was an allegation of abuse and was reportable, so she immediately called Staff L, RM. She said the phone reception was not good so she kept saying to the RM, Can you hear what I'm saying, because she wanted to make sure the RM was made aware of the allegation. She said the RM did not call her back. A review of the admission Record, dated 06/20/2024, showed Resident #81 was admitted on [DATE] with diagnoses to include but not limited to, major depressive disorder, recurrent, unspecified, anxiety disorder, unspecified, schizophrenia, unspecified, need for assistance with personal care A review of the Minimum Data Set (MDS) Assessment, dated 5/12/2024, showed a Brief Interview for Mental Status (BMS) score of 15, indicating intact cognition. A review of a progress note, dated 6/20/2024, showed on 6/13/2024 Resident #81 received a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105566 If continuation sheet Page 3 of 21 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 06/20/2024 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few psychotherapy visit for psychological evaluation and treatment for stabilization of depressed and irritable mood. Resident # 81 was also assessed for mental and emotional status after he reported a Certified Nursing Assistant yelled at him and punched him in the back after putting oil on him. Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation, revised September 2023, showed the following: -All team members are required to report suspected maltreatment to their immediate Supervisor or Director of Quality Assurance/ designee or Executive Director. Notifications can take place in person or via telephone. The employee must report to a department manager or supervisor in the center so that the resident may immediately be protected from further maltreatment. -The center also must report all alleged violations of any type of abuse or any event that led to significant bodily injury immediately but no later than 2 hours from the time of the allegation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105566 If continuation sheet Page 4 of 21 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 06/20/2024 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Residents Affected - Some 3. Review of Resident #10's admission Record revealed the resident was admitted on [DATE] with diagnoses not limited to unspecified depression and unspecified anxiety disorder. Review of Resident #10's Medication Administration Record (MAR) revealed the physician had ordered the medication Trazodone 100 milligram (mg) to be administered to the resident at bedtime, start on 4/1/24. Review of Resident #10's Preadmission Screening and Resident Review (PASRR), dated 8/28/23, did not show the resident had any Mental Illness (MI) or suspected MI, Intellectual Disability (ID) or suspected ID. The findings were based on individual, legal representative or family report. The PASRR showed no diagnosis or suspicion of Serious MI or ID was indicated and a Level II PASRR evaluation was not required. The PASRR was completed by an acute care facility three days (8/28/23) prior to the resident's admission to the facility. 4. Review of Resident #65's admission Record revealed the resident was originally admitted on [DATE] and readmitted on [DATE] and 2/6/24. The record showed the resident was admitted on [DATE] with a diagnosis of unspecified bipolar disorder, a 5/30//22 admission diagnosis of unspecified psychosis not due to a substance or known physiological condition, a diagnosis of unspecified mood (affective) disorder occurring during stay with onset of 3/10/23, and admission diagnoses with onset date of 6/12/23 of unspecified depression, severe current episode depressed bipolar episode with psychotic features, and unspecified severity unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. Review of Resident #65's Preadmission Screening and Resident Review (PASRR), dated 2/24/22, showed a Mental Illness (MI) of bipolar and no diagnosis of depression, anxiety, and/or dementia. Review of Resident #65's Level II Determination, dated 4/22/21, revealed the resident had a reported medical history including Bipolar Disorder, most recent episode depressed, and major depressive disorder. The evaluation showed the resident's Level I PASRR, completed on 4/21/21, revealed the resident was exhibiting serious difficulty with interpersonal functioning and met the state definition of Serious Mental Illness. Review of Resident #65's Level II Determination did not reveal the resident had a diagnosis of anxiety or dementia. Review of Resident #65's Medication Administration Record (MAR) showed the resident was receiving the following medications related to mental illness diagnoses: - Divalproex Sodium Oral Tablet Delayed Release 125 milligram (mg) - Give 1 tablet by mouth three times a day for bipolar disorder. - Lorazepam tablet 0.5 mg - Give 0.5 mg by mouth at bedtime for anxiety. - Paroxetine HCl oral tablet 10 mg - Give 1 tablet by mouth in the morning related to unspecified depression. - Quetiapine Fumarate oral tablet 100 mg - Give 1 tablet by mouth two times a day for bipolar (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105566 If continuation sheet Page 5 of 21 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 06/20/2024 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 0645 disorder. Level of Harm - Minimal harm or potential for actual harm 5. Review of Resident #69's admission Record revealed an admission date on 7/16/21. The record showed the admitting diagnosis on 12/11/23 was unspecified Alzheimer's disease and diagnoses present on admission, dated 7/24/23, was mild recurrent major depressive disorder and unspecified anxiety disorder. Residents Affected - Some Review of Resident #69's Preadmission Screening and Resident Review (PASRR), dated 7/14/21, did not reveal a MI, SMI, ID, or SID with the findings based on documented history. The PASRR did not reveal the resident had a primary or secondary diagnosis of Alzheimer's disease and no Level II evaluation was required. Review of Resident #69's Medication Administration Record (MAR) showed the resident was receiving the following medications related to mental illnesses: - Depakote Sprinkles Oral Capsule Delayed Release 125 mg - Give 2 capsules by mouth at bedtime for mood disorder. - Lexapro 10 mg - Give 1 tablet by mouth in the morning for depression. - Melatonin 3 mg - Give 1 tablet by mouth at bedtime for insomnia. - Buspirone 5 mg - Give 1 tablet by mouth two times a day for anxiety. During an interview on 6/20/24 at 10:00 a.m., the Director of Nursing (DON) reviewed the PASRR's of Resident #10, #65, and #69 confirming the PASRR's should have been redone to include current diagnoses. 6. A review of the admission Record showed Resident #43 was initially admitted to the facility on [DATE] with diagnoses to include unspecified dementia, unspecified severity, with other behavioral disturbance, unspecified psychosis not due to a substance or known physiological condition, and major depressive disorder. A review of Section I- Active Diagnoses of the Minimum Data Set (MDS), dated [DATE], showed the resident had diagnoses to include non-Alzheimer's Dementia, depression, and psychotic disorder. A review of Resident #43's PASRR, dated 05/04/24, revealed no qualifying mental health diagnosis and that no PASRR Level II was required. On 06/20/24 at 9:47 a.m., the Social Services Director reported he would look at the face sheet to see if the resident had any mental health or psychological diagnoses and look at orders to see if the resident had orders for psychotropic medications when residents are newly admitted into the facility. He confirmed Resident #43 had a psychological diagnoses that was not listed on the PASRR. On 06/20/24 at 9:52 a.m., the Director of Nursing (DON) reported prior to admission into the facility, the admission's team would bring her the PASRR to review. She compares the PASRR with the discharge order list from the hospital. If the resident was on any psychotropic medications and the diagnoses were not checked on the PASRR, she would ask the hospital to correct the PASRR and sometimes she would go in and correct it. The DON confirmed Resident #43's current psychiatric diagnoses were not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105566 If continuation sheet Page 6 of 21 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 06/20/2024 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 0645 listed on the PASRR. Level of Harm - Minimal harm or potential for actual harm A review of the policy titled, Pre-admission Screening for Serious Mental Illness (SMI) ad Intellectually Disabled (ID) Individuals (PASRR), revised on July 2021, showed the following: Residents Affected - Some Procedure: 1. It is the responsibility of the center to assess and assure that the appropriate preadmission screenings, either Level I or Level II, are conducted and results obtained prior to admission and placed in the appropriate section of the resident's medical record. 4. If it is learned after admission that a Serious Mental Illness (SMI) or Intellectually Disabled (ID) Level II screening is indicated; it will be the responsibility of Social Services to coordinate and/or inform the appropriate agency to conduct the screening and obtain the results. 7. Social Services will be responsible for coordinating significant change updates of these screenings, conducted by the appropriate agency. Based on observations, interviews, and record review, the facility failed to ensure Preadmission Screening and Resident Review (PASRR) assessments were updated to include current diagnoses, for six residents (#74, #10, #69, #43, #65, and #5) out of 45 sampled residents. Findings included: 1. During an observation on 06/17/2024 at 12:30 p.m., Resident #74 was in the dining room eating lunch. Resident #74 reached into his pocket and pulled out a 100 dollar bill and put it on the table and said this is for the staff for doing such a great job. He then picked up the money and stuck it back in his pocket. Review of Resident #74's admission Record showed Resident #74 was admitted to the facility on [DATE] with diagnoses of unspecified mood [affective] disorder, seizures, major depressive disorder, and adjustment disorder with anxiety. Review of the Level I PASRR, dated 03/06/2023, showed in Section I-Part A was marked for Depressive Disorder. Section II: Other Indications for PASRR Screen Decision-Making questions 1 through 7 were marked NO. Section III: PASRR Screen Provisional admission or Hospital Discharge Exemption Not a Provisional Admission was marked. Section IV: PASRR Screen Completion, Individual may be admitted to a Nursing Facility (check one of the following): No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required was marked. 2. During an observation on 06/17/2024 at 11:00 a.m., Resident #5 was in her room dressed in a hospital gown. She was observed lying in bed sleeping. During an observation on 06/18/2024 at 10:30 a.m., Resident #5 was in her room lying bed dressed in a hospital gown. During an attempt to interview Resident #5, she was not able to answer questions regarding her care or stay. Review of Resident #5's admission Record showed Resident #5 was admitted to the facility on [DATE] with diagnoses of vascular dementia, psychotic disturbance, mood disturbance, anxiety, major (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105566 If continuation sheet Page 7 of 21 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 06/20/2024 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 0645 depressive disorder, seizures and anxiety disorder. Level of Harm - Minimal harm or potential for actual harm Review of the Level I PASRR, dated 04/21/2017, showed in Section I-part A, part B, and related conditions all had a line drawn through and a handwritten NA (not applicable) was noted. Section II: Other Indications for PASRR Screen Decision-Making questions 1 through 7 were marked No. Residents Affected - Some Section III: PASRR Screen Provisional admission or Hospital Discharge Exemption Not a Provisional Admission was marked. Section IV: PASRR Screen Completion, Individual may be admitted to a Nursing Facility (check one of the following): No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required was marked. During an Interview on 06/20/2024 at 9:45 a.m., the Assistant Executive Director, stated they go over PASRR in the morning meetings by confirming new admission PASRR's are complete. If the PASRR is not correct the Director of Nursing (DON) updates the PASRR. He stated the verify if the PASRR is correct by checking the face sheet and 3008 from the hospital for any diagnosis of psychological or mental health. He stated then they will check to see if the resident was being prescribed any antipsychotic, or mood disorder medications. He stated If there was a diagnosis of psychological or mental health but no medications, he would not update the PASRR. He stated if a new diagnosis is added for residents they talk about it in the standard of care meetings. He stated then the DON will complete any updates as needed. During an interview on 06/20/2024 at 10:00 a.m. with the DON she stated before the residents come in; admissions brings the PASRR to her to confirm it is correct. She stated she uses the discharge order list of medications to determine any anti-psych (psychotic) meds (medications) to confirm their diagnosis match what is marked on the PASRR. If the PASRR is incorrect before admissions, they try to get the hospital to correct them. She stated for residents who need updated PASRR's social services will notify her when they need to be updated. She was unsure how often social services reviews or audits the PASRR's for residents who have a new diagnosis and require an updated PASRR. She reviewed the PASRR for Resident# 74 and Resident #5 and confirmed the PASRR's had not been updated to match the most current diagnosis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105566 If continuation sheet Page 8 of 21 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 06/20/2024 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review, the facility failed to accurately assess and document the skin condition for one resident (#69) out of three residents sampled for skin conditions. Residents Affected - Few Findings included: On 6/18/24 at 10:46 a.m., an observation was conducted of Resident #69 during the administration of medications. The observation revealed the resident's bilateral feet were extremely dry with dry, tan-colored ridged scale-like overgrowth of skin visible on the bottom of one foot and toenails on both feet were thick, yellowed and long. The resident had scratches on bilateral arms. Review of Resident #69's Order Summary Report, active as of 6/19/24 at 3:20 p.m., revealed the following orders: - Halobetasol propionate external cream 0.05% - Apply to entire body topically every day and evening shift for atopic dermatitis for 4 weeks. Ordered on 6/12/24. Review of Resident #69's Weekly Skin check, effective 6/13/24, showed the resident's skin was intact. Review of a nursing note, dated 6/19/24 at 1:35 a.m., revealed Resident #69 voiced no discomfort and skin was warm, dry, and intact. The note did not reveal the bottom of the resident's feet was thickened and scaly. An interview was conducted on 6/19/24 at 1:16 p.m., with Staff H, Certified Nursing Assistant (CNA. The staff member reported noticing the skin on Resident #69's feet and stated she puts the facility body lotion on it. An interview was conducted on 6/19/24 at 1:20 p.m., with Staff I, Registered Nurse (RN). The staff member stated the resident's feet seem to have an overgrowth of skin and he noticed it about 2 weeks ago but has not told the physician about it. The staff member reported putting lotion on the feet to try to soften it up. Staff I stated at first he thought it was dry skin but it was not. Staff I stated he could call the physician about it and the resident had not complained of pain in the toenails, but he could cut them if it was needed. The staff member agreed the skin on the resident's feet was tan-colored and scaly and reported using the facility's individual packets of lotion on them. An interview was conducted on 6/19/24 at 1:40 p.m. with Staff C, RN/Unit Manager (RN/UM), the staff member reported the weekly skin assessment is a head-to-toe assessment and skin conditions should be noted, rashes, redness, pressure ulcers, scratches, or bruises, any abnormality of the skin. An observation was conducted on 6/19/24 at 1:40 p.m. with Staff C of Resident #69's right foot. The resident stated yes when asked if the feet hurt. Staff C took the sock off the resident's right foot and the resident winced and pulled away from the staff member confirming the feet hurt. The staff member stated weekly skin checks are done and the area to bilateral feet should have been noted on the assessment. Staff C stated she could not say it wasn't there at the time of the last weekly skin assessment. The staff member called the provider describing the bottom of the resident's feet was an overgrowth of skin, possible fungus not a callus. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105566 If continuation sheet Page 9 of 21 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 06/20/2024 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 0684 Review of the Order Summary Report showed an order, dated 6/19/24 for: Level of Harm - Minimal harm or potential for actual harm - Triamcinolone Acetonide External cream 0.1% - Apply to left foot topically every day and evening shift for dryness for 14 days. Residents Affected - Few - Triamcinolone Acetonide External cream 0.1% - Apply to right foot topically every day and evening shift for dryness for 14 days. An interview was conducted on 6/20/24 at 11:48 a.m. with Staff C, the staff member reported washing and applying lotion to Resident #69's bilateral feet and the area did soften. The staff member stated the areas were not dirt. Staff C stated the Advanced Registered Nurse Practitioner (ARNP) changed the order to the resident's feet today. During an interview on 6/20/24 at 12:07 p.m., the Director Nursing (DON) stated dermatology had seen Resident #69 on 6/11/24 and identified bilateral feet keratoderma and had prescribed Halobetasol 0.05% cream twice daily x 4 weeks. The DON stated keratoderma was a thickening of the palms of hands and bottom of feet. Review of Resident #69's dermatology report, dated 6/11/24, revealed the resident was last seen on 5/29/24 and presented with the following complaints: atopic dermatitis (follow up) and involves the body, seborrheic dermatitis (follow up) involving the face, and Xerosis cutis (follow up) involving the left lower extremity, right lower extremity, right upper extremity, and left upper extremity. The physical exam of the resident showed: -Atopic dermatitis, chronic - improved. Generalized pink erythematous scaly plaques involving head, neck, chest, abdomen, back, pelvis, upper extremities, (and) lower extremities. -Seborrheic dermatitis, chronic - improved. Pink erythematous patches with fine white scale (face) -Xerosis cutis, chronic - improved. Dehydrated skin showing erythema, scaling and fine crackling left lower extremity, right lower extremity, right upper extremity, (and) left upper extremity. -Keratoderma bilateral feet - start Halobetasol 0.05 cream twice daily x 4 weeks. Review of Resident #69's Weekly Skin Check, effective 6/13/24, provided by the facility, revealed skin was impaired, Entire body with dermatitis. Improved. Ordered in Place. The skin check was signed by a Licensed Practical Nurse (LPN) on 6/19/24. Review of Resident #69's RN/LPN Skin Grid, effective 6/19/24 at 1:18 p.m., showed the reason for completion was Weekly until the injury has healed. The evaluation showed Entire body with dermatitis. Ordered in Place. The evaluation was signed by an LPN staff member on 6/19/24. Review of a Situation, Background, Appearance, Review and Notify (SBAR), showed the change in condition was Dry scaly skin to bilateral feet. The appearance summarized observations and evaluation was dry/scaly skin to bilateral feet. Feet cleaned with soap and water, dried and lotion applied. The evaluation showed the physician was notified on 6/19/24 at 1:45 p.m. and the family member was called on 6/19/24 at 2:55 p.m. Review of the policy - Skin Care & Wound Management, revision July 2017, showed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105566 If continuation sheet Page 10 of 21 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 06/20/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm As part of an ongoing Quality Assurance process, skin care, and wound management guidelines are to provide necessary treatment and services to promote healing, prevent infection, control pain and prevent development of pressure injury(s) unless the resident's clinical condition demonstrates that they were unavoidable. The resident's right to pain management will be respected and supported. The resident will also be encouraged to be a partner in care. The guidelines for skin care and wound management include: Residents Affected - Few - Skin inspection on a regular and ongoing basis to provide documentation and prompt interventions of any changes noted. - Manage wound care using guidelines based upon current standards of practice. - Observe for signs of infection and manage infection. - Monitor resident response to interventions for prevention and/or treatments and revise the care plan based on response, outcomes, needs and resident wishes. The Skin Grid - Other will be completed upon identification of impaired skin at admission, at hospital return, at the time a surgical wound, venous stasis wound, diabetic wound, burn, skin tear, laceration, abrasion, rash, MAD (moisture associated dermatitis) or any other significant skin condition is found. The skin grid will be updated no less than every seven (7) days until the skin condition/wound is healed. One site will be documented per page with additional information documented as a narrative nurse's note. The Weekly Skin Sweep will be used by the licensed nurse to conduct a skin inspection at the time of admission, upon hospital return and no less than every seven (7) days. A skin inspection will also be completed before and after a leave of absence from the center and if time permits before a hospital transfer. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105566 If continuation sheet Page 11 of 21 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 06/20/2024 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 0699 Provide care or services that was trauma informed and/or culturally competent. 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 interview, the facility failed to ensure one resident (#7) out of the one sampled resident was appropriately assessed related to Post Traumatic Stress Disorder (PTSD). Residents Affected - Few Findings included: A review of the admission Record for Resident #7 showed he was initially admitted to the facility on [DATE] with a diagnosis to include PTSD. A review of Section C- Cognitive Patterns of the Minimum Data Set (MDS), dated [DATE], showed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating cognitively intact. Section I- Active Diagnoses of the MDS showed the resident had a diagnosis of PTSD. A review of the Clinical admission record, dated 06/07/24, showed the Trauma Informed Care Screening was not completed. Further review of the medical record showed the Trauma Informed Care Screening was present in the medical record. On 6/19/24 at 10:49 a.m. an interview was conducted with the Director of Nursing (DON). The DON stated a Trauma Informed Care Assessment should be completed by nursing upon admission to the center. The DON stated the Unit Managers are responsible to double check and make sure the sections on the clinical admission evaluations are complete. A review of the policy titled. Trauma Informed Care, with an effective date of 11/01/19, revealed the following: Process: All residents admitted to facility will have a Brief Trauma Questionnaire (BTQ) performed at the time of admission. The Social Services Director or Designee will complete the BTQ for all newly admitted residents upon admission. When Trauma has been identified the Social Services Director or Designee will inform the resident's attending physician and request both Psychiatry and Psychology for the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105566 If continuation sheet Page 12 of 21 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 06/20/2024 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 review, the facility failed to ensure the medication error rate was less that 5.00%. Twenty-six medication administration opportunities were observed and three errors were identified for two residents (#69 and #98) out of six residents observed. These errors constituted a 11.54% medication error rate. Residents Affected - Few Findings included: On 6/18/24 at 10:46 a.m., an observation was made of Staff I, Registered Nurse (RN). Staff I dispensed the following medications for Resident #69: -Breo Ellipta 200 microgram/25 microgram (mcg/mcg) inhaler -Buspirone 5 milligram tablet -Calcium carbonate oral chewable antacid over the counter (OTC) tablet -Cetirizine 10 milligram (mg) OTC tablet -Vitamin D 25 mcg (1000 international unit) OTC tablet -Combivent Respimat 20 mcg/100 mcg inhaler -Escitalopram 10 mg tablet The staff member confirmed dispensing 2 inhalers, one chewable tablet, and 4 oral tablets. Upon entering the resident room, Resident #69 was non-verbal. The staff member administered one inhalation of Breo Ellipta, immediately followed by one inhalation of Combivent, then administered oral tablets before assisting resident with drinking house supplement, and administered the chewable tablet. On 6/18/24 at 10:55 a.m., the staff member returned to the medication cart. The medication administration observation took nine minutes. Review of the Resident #69's June Medication Administration Record (MAR) revealed the following orders related to the observed administration of medications: - Breo Ellipta Inhalation Aerosol Powder 200-25 mcg/act. Inhalation inhale orally in the morning - Chronic Obstructive Pulmonary Disease (COPD). Rinse mouth after use. - Combivent Respimat Aerosol solution. Inhale orally four times a day for shortness of breath/wheezing. Rinse mouth out after use. The observation did not show the resident was offered or advised to rinse mouth out without swallowing after the administration of Breo Ellipta as manufacturer instructions or to rinse mouth out per the Breo Ellipta or the Combivent physician orders. According to the manufacturer informational website, mybreo.com, shows Breo Ellipta contains an inhaled corticosteroid, Fluticasone furoate and the long-acting beta2-adrenergic agonist ([NAME]), (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105566 If continuation sheet Page 13 of 21 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 (X3) DATE SURVEY COMPLETED A. Building 06/20/2024 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 - Few vilanterol. The informational supplement advises users Breo can cause serious side effects including: fungal infection in your mouth or throat (thrush). Rinse your mouth with water without swallowing after using BREO to help reduce your chance of getting thrush. According to the manufacturer, Boehringe-Ingelheim, https://pro.boehringer-ingelheim.com/us/products/combivent/about-combivent-respimat, the medication Combivent contains 2 short-acting bronchodilators: anticholinergic component and a beta-2 adrenergic receptor. Review of policy titled Medication Administration, dated 07/2023, revealed the following: Purpose: To administer the following according to the principles of medication administration, including the right medication, to the right guest/resident at the right time, and in the right dose and route. Procedure: - Verify physician's orders for medications to be administered. - Review any special precautions and perform needed evaluations prior to administering medication to the guest/resident. - Read the Medication Administration Record (MAR) for the ordered medication, dose, route, and time. - Verify/clarify orders as needed prior to administration. Review of policy titled Medication Administration - Metered Dose Inhaler (MDI), dated 7/2023, revealed the following: Purpose: To administer an inhalation medication into the tracheobronchial tree. The procedure for administration included: - Compare the medication with the Medication Administration Record (MAR). - Instruct and/or assist the guest/resident to shake canister for 30-45 seconds before actuation. - Instruct guest/resident to exhale to end tidal volume (empty lungs), place tip of spacer in mouth and maintain a tight seal, as indicated. - Instruct guest/resident to activate the inhaler during the first third of a slow maximal inhalation and continue to inhale until lungs are filled with air. - Wait at least one minute for multiple inhalations of same drug; wait at least two minutes if switching to a different drug repeat Steps 8 - 10 until the prescribed dosage has been administered. - Instruct guest/resident to rinse mouth, especially if a steroid was administered. - Evaluate respiratory status to include, but not limited to: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105566 If continuation sheet Page 14 of 21 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 06/20/2024 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 o Level of Harm - Minimal harm or potential for actual harm Breath sounds o Residents Affected - Few Cough effort and sputum production o Heart rate o Respiratory rate On 6/18/24 at 11:49 a.m., an observation was made with Staff J, Registered Nurse (RN), obtain a blood glucose level, prepare medication, and inject Resident #98's insulin. Staff J assisted the resident back to room, washed hands, donned gloves, cleaned the resident's right index finger with an alcohol pad, lanced the finger, and obtained a blood sample revealing a blood glucose level of 250. On 6/18/24 at 11:56 a.m., Staff J removed Resident #98's Lispro Kwikpen from the medication cart, placed an insulin needle on the pen, dialed 8 units on the dosage selector, and returned to the resident's room. The staff member cleansed the resident's right lower abdominal quadrant with an alcohol pad, the dosage selector of 8 units was verified prior to the injection of the insulin. The staff member verified the dosage selector had returned to zero. The staff member walked back to the medication (parked at nursing station) with pen and needle in a gloved hand. On 6/18/24 at 12:05 p.m., Staff J stated she did prime the insulin pen a little, demonstrating with dial selector pointed upwards. The staff member stated, Yes primes the pen pointing downwards. The staff member stated, Sorry when observation of no priming of the insulin pen was discussed. Review of Resident #98's Medication Administration Record (MAR), June 2024, revealed a sliding scale showing the units to be delivered per the blood glucose level. The sliding scale showed a blood glucose of 221-260 was to be administered 8 units. The MAR showed Staff J had documented 8 units had been administered for the afternoon dose of Insulin Lispro on 6/18/24. A review of the facility policy titled Medication Administration Insulin Injection, dated 07/2023, reveal the following: Purpose: To safely administer an insulin injection. The policy does not show the procedure staff should follow to administer with an insulin pen. The manufacturer information for Humalog Insulin Lispro, located at https://uspl.lilly.com/humalog/humalog.html#ug1, reveals the instructions to Priming your Pen - Prime before each injection. The instructions reveal Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. The manufacturer procedure instructs: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105566 If continuation sheet Page 15 of 21 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 06/20/2024 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 - Step 4: Push the capped Needle straight onto the Pen and twist the Needle on until it is tight. Level of Harm - Minimal harm or potential for actual harm - Step 5: Pull off the Outer Needle Shield. Do not throw it away. Pull off the Inner Needle Shield and throw it away. Residents Affected - Few - Step 6: To prime your Pen, turn the Dose Knob to select 2 units. - Step 7: Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. - Step 8: Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. o You should see insulin at the tip of the Needle. o If you do not see insulin, repeat priming steps 6 to 8, no more than 4 times. o If you still do not see insulin, change the Needle and repeat priming steps 6 to 8. Small air bubbles are normal and will not affect your dose. Selecting your dose: - You can give from 1 to 60 units in a single injection. - If your dose is more than 60 units, you will need to give more than 1 injection. If you need help with dividing up your dose the right way, ask your healthcare provider. - Use a new Needle for each injection and repeat the priming step. - Step 9: Turn the Dose Knob to select the number of units you need to inject. The Dose Indicator should line up with your dose. o The Pen dials 1 unit at a time. o The Dose Knob clicks as you turn it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105566 If continuation sheet Page 16 of 21 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 06/20/2024 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 o Level of Harm - Minimal harm or potential for actual harm Do not dial your dose by counting the clicks. You may dial the wrong dose. This may lead to you getting too much insulin or not enough insulin. Residents Affected - Few o The dose can be corrected by turning the Dose Knob in either direction until the correct dose lines up with the Dose Indicator. o The even numbers (for example, 12) are printed on the dial. o The odd numbers, (for example, 25) after the number 1, are shown as full lines. o Always check the number in the Dose Window to make sure you have dialed the correct dose. During an interview with the Director of Nursing (DON) on 6/20/24 at 11:51 a.m., the DON stated insulin pens should be primed before use, dial the (pen) to 3 to 5 units, and prime with the needle upwards. The DON stated when giving 2 inhalers, staff should wait 5 minutes in between, rinse mouth in between each inhaler, and to rinse with water. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105566 If continuation sheet Page 17 of 21 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 06/20/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interviews, and record review the facility failed to ensure food was labeled and expired items were discarded in one nourishment room (100-hall) of two nourishment rooms. Residents Affected - Few Findings included: During an observation on 06/18/2024 at 3:50 p.m. of the 100-hall nourishment room, two cartons of milk were identified to be expired as of 6/14/2024. An additional observation revealed two frozen dinners were in the freezer without a resident's name or room number to identify who they belonged to. During an interview on 06/18/ 2024 at 3:50 p.m. the Unit Manager (UM), confirmed the milk should be discarded and stated the kitchen staff are typically the ones who go through the items in the nourishment rooms. During an interview on 06/18/2024 at 4:00 p.m. with the Certified Dietary Manager (CDM), she stated the food in the freezer should have been dated and labeled with the resident's name. Review of the Food Labeling and Dating Refrigeration policy that was not dated, revealed: Purpose: The center adheres to labeling and dating system to ensure the safety of ready-to-eat, time/temperature control for food safety .Policy explanation and compliance guidelines for staffing: 6. The discard day or date may not exceed the manufacturer's use-by-date, or seven days whichever is earliest. 7. The head cook, or designee, shall be responsible for checking the refrigerator daily for food items that are expiring, and shall discard accordingly. Review of the Resident Personal Food policy that was not dated, revealed: All residents have the right for family members and visitors to provide preferred or requested foods, and fluids from outside of the facility .Procedure: 5. Food must be labeled with resident name and dated . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105566 If continuation sheet Page 18 of 21 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 06/20/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During an observation made on 6/17/2024 at 10:30 a.m., two different infection control signs were posted outside room [ROOM NUMBER] for two residents residing in the same room. Residents Affected - Some 4. An observation on 06/17/24 at 10:30 a.m. revealed Staff A, Housekeeper cleaning in room [ROOM NUMBER]. room [ROOM NUMBER]'s door had a precautions sign that showed, Special Contact Precautions The precautions sign showed, Before entering, everyone MUST: Perform hand hygiene with alcohol-base hand rub or soap and water, Wear Gown before entering and remove upon exiting, and Wear gloves before entering and remove upon exiting. Staff A, Housekeeper did not have a gown on while in the room. Photographic evidence obtained. During an interview on 06/17/24 at 10:30 a.m., Staff A, Housekeeper looked at the Special Contact Precautions sign and stated, That is just for [Certified Nursing Assistants] CNAs. During an interview on 06/17/24 at 10:35 a.m., Staff B, Certified Nursing Assistant (CNA) looked the Special Contact Precautions sign and stated, Everyone must put on gloves and gowns prior to entering room. During an interview on 06/17/24 at 10:45 a.m., Staff C Registered Nurse (RN), Unit Manager (UM) looked at the Special Contact Precautions sign and stated, the resident in the window bed had an infection in the urine. Staff C RN, UM stated, You only need to use [Personal Protective Equipment] PPE when performing care on the resident. During an interview on 06/17/24 at 10:50 a.m., the Director of Nursing (DON)/Infection Preventionist (IP) stated, the facility did monthly training on infection control. The DON/IP stated rooms designated as Special Contact Precautions rooms would require everyone to don a gown and gloves prior to entering those rooms, including non-clinical staff such as housekeeping who would be in contact with the environment in the room. During an interview on 06/19/24 at 10:13 a.m., Staff D, Housekeeper stated housekeeping staff are required to follow the precautions signs located on the residents' doors. During an interview on 06/19/24 at 1:07 p.m., the DON/IP stated for the rooms observed with both Enhanced Barrier Precautions and Contact Precautions signs posted on the door could be confusing. The DON/IP stated she could see how it would cause confusion as one sign Enhanced Barrier Precautions advised to only wear a gown and gloves for direct care and the other sign Contact Precautions advised everyone that they must wear gown and gloves to enter the room. The DON/IP stated that she had the least restrictive signs taken down so that everyone must wear a gown and glove when entering those respective rooms. Review of the facility's policy titled Isolation-Categories of Transmission- Based Precautions, revised date August 2012, showed the following: Contact Precautions: In addition to Standard Precautions, implement Contact Precautions for residents known or suspected to be in infected with microorganisms that can be transmitted by direct contact with resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. The decision on whether precautions are necessary will be evaluated on a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105566 If continuation sheet Page 19 of 21 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 06/20/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm case-by-case basis. c. Gloves and Handwashing (1) In addition to wearing gloves as outlined under Standard Precautions, wear gloves (clean, non-sterile) when entering the room. d. Gown (1) Wear disposable gown upon entering the Contact Precaution room or cubicle. Photographic evidence obtained. Residents Affected - Some Based on observations, interviews, and record reviews, the facility failed to implement an effective infection control program related to ensuring staff were educated on transmission-based precautions (TBP) and the personal protective equipment (PPE) to be worn when entering isolation precaution rooms, and failed to ensure signage was posted related to the type of TBP for two residents (#44 and #83) out of two residents sampled for isolation precautions. Findings included: On 6/17/24 at 9:54 a.m., an observation was made of the area outside of Resident #44's room. A caddy holding gloves, blue gowns, and red biohazard bags hung on the hallway side of the door. The area outside of the room did not show the type of PPE staff were to wear or when to wear PPE during the care of Resident #44. An interview was conducted on 6/17/24 at 10:15 a.m., with Staff E, Certified Nursing Assistant (CNA) as the staff member was leaving Resident #44's room. The staff member stated the resident was on contact precautions. An interview was conducted on 6/17/24 at 11:10 a.m. with Staff F and Staff G, Licensed Practical Nurses (LPN). The staff members stated Resident #44 was on contact precautions because of a wound. During an interview on 6/17/24 at 2:39 p.m., Resident #44 stated being on precautions due to having yeast in urine. Review of Resident #44's physician orders revealed the following: - Cleanse the Trauma/Injury to Right Knee with normal saline (NS), pat dry, apply Hydrofera Blue, and cover with dressing (BDR) every day shift every 3 day(s). Dated 6/14/24. - Cleanse the Trauma/Injury to Right Knee with normal saline (NS), pat dry, apply Hydrofera Blue, and cover with dressing (BDR) as needed. Dated 6/14/24. - Enhanced Barrier Precautions every shift for Candida Auris. Dated 2/5/24. The review of Resident #44's physician orders did not reveal an order for contact precautions as reported by staff members. On 6/19/24 at 9:48 a.m., an observation revealed Resident #44's doorframe was posted with a sign showing staff were to use Enhanced Barrier Precautions while performing high-contact care for the resident. 2. On 6/17/24 at 10:33 a.m., an observation was made of Resident #83 lying in bed with nutritional fluid running at 35 milliliter/hour (mL/hr). The resident was non-verbal, with poor dentition, and had a shirt in the mouth. The observation revealed no signage for precautions or Personal Protective (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105566 If continuation sheet Page 20 of 21 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 06/20/2024 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 0880 Equipment (PPE) available at the doorway. Photographic evidence was obtained. Level of Harm - Minimal harm or potential for actual harm On 6/17/24 at 10:53 a.m., an observation was made of Staff I, Registered Nurse (RN) standing next to the bed of Resident #83 hanging a bottle of nutrition without wearing PPE, and Staff C, RN/Unit Manager (UM) was standing in the doorway to the room. Staff C stated Resident #83 had changed rooms awhile ago and confirmed Enhanced Barrier Precautions (EBP) should have followed the resident. Staff I left the room and confirmed hanging a nutrition bottle. A few moments later, Staff C was observed hanging a PPE caddy on the door to the resident's room with an Enhanced Barrier Precaution sign. Residents Affected - Some During an interview on 6/20/24 at 12:00 p.m. the Director of Nursing stated Resident #83 should have had EBP due to a feeding tube and wounds. The DON reported transmission-based precautions were reviewed at time of orientation and Staff I had just done through orientation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105566 If continuation sheet Page 21 of 21