Inspection·March 25, 2021

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the facility's electronic maintenance system log dated January to March 2021 did not show the above bathroom floor maintenance concerns nor the 3 residents' wheelchair disrepairs. On 3/25/21 from 11:40 AM to 12:05 PM, observations of the above resident bathrooms and wheelchair concerns were conducted with the Maintenance Director. The Maintenance Director acknowledged the above 3 bathroom broken tiles, missing transition floor strips, and the 3 resident wheelchairs in need of repair. He acknowledged he had not been notified of the concerns by staff. He said the process to report maintenance repair requests was for staff to enter the concern into the electronic maintenance program. He acknowledged the concerns were not in the log. A Policy and Procedure regarding facility maintenance and resident equipment was requested from the Administrator and Maintenance Director. On 3/2521 a 4:25 PM, the Administrator stated the facility did not have a written policy that addressed facility maintenance and/or resident equipment maintenance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105577 If continuation sheet Page 2 of 12 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 105577 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/25/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Orlando 654 N Econlockhatchee Trail Orlando, FL 32825 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 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide shaving and nail care for 2 of 3 sampled residents who required staff assistance with personal hygiene and grooming, of a total sample of 45 residents, (#80 and #27). Residents Affected - Few Findings: 1. Resident #80 was admitted to the facility on [DATE] from an acute care hospital with a primary diagnoses of intellectual disabilities, need for assistance with personal care, generalized muscle weakness, muscle wasting and atrophy, and cognitive communication deficit. The resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had long and short term memory problems. The MDS indicated the resident required extensive assistance from one person for personal hygiene, required physical help from one person with bathing, and the resident's behavior showed he did not reject care. Review of resident #80's care plan dated 11/18/2020 and revised on 03/24/2021 revealed a plan for activities of daily living (ADL,) self-care and /or mobility deficits. It noted the resident required limited to extensive assistance with hygiene and bathing. The care plan also included a focus on impaired communication with interventions that included staff to anticipate and meet needs. On 03/22/2021 at 11:00 AM, the resident in bed. He was able to answer yes and no questions by verbalization and gestures. The resident was unshaven with growth of hair approximately one half inch on his face. His nails were long with a dark substance under the nails on his right hand. The resident affirmed he wanted his face shaved and his hands and nails cleaned. On 03/23/2021 at 12:40 PM, the resident was in bed, awake and alert. His nose was dirty and he had white flakes on his scalp. His face was unshaven and his nails remained long, with sharp edges and a dark residue under the nails. The resident again confirmed he had not been bathed or shaved. He indicated he wanted his face shaved and nails cleaned. On 03/23/2021 at 1:15 PM, Certified Nursing Assistant (CNA) B acknowledged the resident's nails were long and dirty and his facial hair was long. She stated that residents were supposed to be bathed everyday and that included nail cleaning and shaving. She stated she usually asked residents if they wanted to be shaved and have their nails trimmed and cleaned during bathing. Review of the CNA daily assignment dated 03/22/2021 revealed the resident's shower days were Tuesday and Friday on the 3-11 shift. A review of the resident's CNA task flowsheet for March 2021 revealed that showers were given to the resident on 03/02/2021, 03/05/2021, 03/09/2021, 03/12/2021, 03/16/2021, and 03/23/2021. He was provided baths on 03/07/2021, 03/09/2021, 03/20/2021, and 03/21/2021. A review of the ADL flowsheet dated from 03/11/2021- 03/24/2021 revealed the resident was totally dependent on staff for personal hygiene needs and bathing. A review of bathing and personal hygiene self performance and support provided on the ADL flowsheet revealed no refusals documented. Per the form personal hygiene needs included shaving and washing/drying of hands. 2. Resident #27 was admitted from an acute care hospital on [DATE] with diagnoses of Coronavirus (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105577 If continuation sheet Page 3 of 12 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 105577 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/25/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Orlando 654 N Econlockhatchee Trail Orlando, FL 32825 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 Disease 2019 (Covid 19), legal blindness, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side. Review of the resident's Medicare 5 day MDS assessment dated [DATE] revealed he had a Brief Interview for Mental Status score of 7 which indicated his cognition was severely impaired. The assessment indicated the resident needed extensive assistance of one staff person for personal hygiene and bathing. On 03/22/2021 at 11:10 AM, the resident was lying in bed wearing a shirt and pants listening to music. He was alert and oriented to person, place and time. He stated he was blind from a previous stroke. His face was unshaven, with hair approximately one third inch long. His nails were dirty with a dark substance under them. The resident said he frequently scratched his skin, making it bleed and got under his nails. The resident stated he had a bed bath earlier in the day, but no one offered to clean his nails or shave his face. He said he wanted his face shaved and his nails cleaned. On 03/23/2021 at 12:45 PM, the resident was sitting up in bed eating from his lunch tray with dirty nails. The resident was still unshaved, the stubble on his face was approximately one-third of an inch long. He again stated he would like to be shaved. He said no one had cleaned his nails, but he had been bathed that morning. He stated that he was able to wash his hands but he was unable to clean under his nails as he couldn't see. On 03/23/2021 at 1:15 PM, CNA B entered the resident's room to pick up his lunch tray. She acknowledged the resident had dirty nails and she noted that he had blood and skin under his nails from frequently scratching himself. The CNA stated the resident was to be bathed everyday which included nail cleaning, and shaving. She said the residents were shaved if they needed it and acknowledged the resident needed to be shaved. She verbalized the resident was bathed earlier today but she had not asked him if he wanted to be shaved or cleaned his nails. She verified the resident ate his lunch with dirty nails. The ADL Flowsheet showed the resident was scheduled for showers on Mondays and Thursdays during the 7-3 shift. Bed baths were documented as given on 02/25/2021, 03/01/2021, 03/04/2021, 03/08/2021, and 03/22/2021. He had sponge bath on 03/18/2021. The resident had a shower on 03/11/2021 and 03/15/2021. The flowsheet indicated he was totally dependent on staff for bathing, and limited to totally dependent on staff for personal hygiene ADL's. Review of the care plan dated 01/2/2021, revealed the resident had an ADL Self- Care and/or mobility deficit. It read he needed help ranging from supervision to extensive assistance with hygiene and bathing. On 03/24/2021 at 4:35 PM, the Director of Nursing (DON) stated the expectation was that, the CNA's do ADL care, bathing, showers, teeth brushing, nail cleaning, and shaving. She said that resident's nails and hands need to be cleaned every day, before meals and also as needed. She added, If they are dirty they should be cleaned immediately. She stated that, ADL care is done every shift, on the AM shift the nails need to be cut or cleaned and they should be checked. Shaving is part of the ADL care. Shaving should be done during AM care. She noted that even if the resident was confused, the CNA needed to ask them if they wanted to be shaved. She stated they are supposed to attempt/ask if the resident wants a shave, and not wait for the resident to ask for a shave. Review of the CNA job description dated September 2019 revealed that CNA's are to provide (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105577 If continuation sheet Page 4 of 12 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 105577 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/25/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Orlando 654 N Econlockhatchee Trail Orlando, FL 32825 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 assistance with care as directed including baths and AM and PM care. Level of Harm - Minimal harm or potential for actual harm Review of the facility's policy, Bathing, Grooming and Dressing dated April 2017 revealed the purpose of these procedures are to promote cleanliness and comfort, and to observe the condition of the resident's skin. The equipment listed included razor (electric or disposable), nail clippers, nail file, emery board and orange stick. The procedures listed in bathing, grooming and dressing section include a step by step guide for shaving with a disposable or electric razor and nail care. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105577 If continuation sheet Page 5 of 12 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 105577 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/25/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Orlando 654 N Econlockhatchee Trail Orlando, FL 32825 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide dressing changes for a midline intravenous (IV) catheter according to current professional standards of practice for 2 of 3 residents with midline IV's, of a total sample of 45 residents, (#416 and #415). Residents Affected - Some Findings: 1. Resident #416 was admitted to the facility from an acute care hospital on [DATE] with diagnoses including urinary tract infection (UTI). She had a Midline IV catheter inserted on 03/10/2021 in the left arm for administration of IV antibiotics. She received Ertapenem (IV antibiotic) daily for UTI thru 03/20/2021. A midline catheter is put into a vein by the bend in your elbow or your upper arm .The midline tube ends in a vein below your armpit .midline catheter may allow you to receive long-term intravenous (IV) medicine or treatments . (www.drugs.com). On 03/22/2021 at 12:50 PM, resident #416 was sitting up in bed wearing a hospital gown. An IV pole with an empty bag of Ertapenem and used IV tubing were hanging from the pole. The resident stated she was at the facility for treatment with IV antibiotics for a UTI. She said she was concerned with the way her IV site dressing looked. She had a transparent dressing on her left upper arm midline IV site with no date on it. The dressing was lifting up from the skin, with tape curled up and hanging down from the bottom. The gauze under the clear dressing was soiled with dark brown substance. The resident stated that no one had changed the dressing on her IV, but they had replaced the tape on the dressing. On 03/22/2021 at 1:35 PM, Registered Nurse (RN) A acknowledged the resident's IV dressing was loose with tape hanging from the dressing, not dated, and the soiled gauze. She noted the dressing needed to be changed. On 03/22/2021 at 1:45 PM, RN A stated that resident #416's medical record showed there were no orders in place for dressing changes to the midline IV nor was there evidence of any previous dressing changes made to the IV site. RN A stated that dressings on midline IV's need to be changed 24 hours after insertion because the gauze collects blood and it could cause infection. After that dressings should be changed every 7 days and also as needed. RN A said there were batch orders for the nurses to enter for IV care but the orders were not added to the resident's medical record and dressings were never changed. The Admission/Medicare Five day minimum data set (MDS) dated [DATE] showed resident #416 had a brief interview mental status (BIMS) score of 14, which indicated she was cognitively intact and she had a UTI in the last 30 days. A review of the Order Summary Report dated 03/22/2021 revealed no orders for IV dressing changes. An order dated 03/10/2021 read, Observe site every shift .Observe site before and after medication administration and during dressing changes every shift. The resident's care plan was initiated on 03/10/2021 with a focus on the potential for complications related to midline placement for antibiotics (ABT) completion. Interventions included, change (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105577 If continuation sheet Page 6 of 12 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 105577 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/25/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Orlando 654 N Econlockhatchee Trail Orlando, FL 32825 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 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some dressing to IV site per orders/facility policy and monitor IV site for signs and symptoms of infection such as pain, swelling, redness and drainage. On 03/25/2021 at 12:20 PM, the Director of Nursing (DON) stated the expectation was for nurses to follow the dressing change protocol which was for midline dressings to be changed 24 hours after insertion, then at least weekly, and as needed using a clear dressing. She said the dressing needed to be changed within the first 24 hours to prevent infection. She added the expectation was for the nurse to place the orders for dressing changes when a resident had the midline placed or if they were admitted to the facility with it. The DON noted there were no orders for midline dressing changes ever placed for resident #416. She stated the midline IV site should not have gauze under the clear dressing past the first 24 hours after it was inserted and if there was gauze under the clear dressing it meant it was not changed. She said that the gauze would also prevent the nurse to visualize the site to observe for infection or other problems. 2. Resident #415 was admitted to the facility from an acute care hospital on [DATE] with diagnoses including Methicillin Resistant Staphylococcus Aureus (MRSA) infection, and cutaneous abscess of the right lower limb. He received Vancomycin (IV antibiotic) daily for MRSA right leg wound through 03/23/2021. On 3/22/2021 at 11:30 AM, resident #415 was awake and alert, lying in bed watching television. He had a midline IV to his left upper arm with gauze visible under the clear dressing. The IV dressing was not dated, timed or initialed. On 03/22/2021 at 1:25 PM, RN A acknowledged the resident had a midline IV to his left arm with gauze visible under the clear dressing which was not dated. On 03/22/2021 at 1:45 PM, RN A stated the resident's IV dressing should have been changed initially on Saturday, 03/20/2021, 24 hours after insertion but it was not done. She said there was a note from the IV company's insertion document dated 03/19/2021 to change the dressing in 24 hours. She noted there there was a physician order dated 03/18/2021 to change the dressing on admission, 24 hours after insertion, if applicable and as needed, but it was not done. Review of the medical record revealed physician orders dated 03/18/2021 that read: Change the dressing on admission, 24 hours after insertion if applicable. Observe the site every shift with intermittent therapy or when not in use. Observe the site before and after medication administration and during dressing changes. Observe site every 2 hours during continuous therapy. Review of the resident's Medication Administration Record (MAR) and nursing progress noted from 03/18/2021 to 03/22/2021 revealed no documentation that any dressing change was made to the midline IV site. Resident #415's care plan initiated on 03/19/2021 revealed a focus on the potential for complications related to midline placement for antibiotics (ABT) completion. The interventions included, change dressing to IV site per orders/facility policy and monitor IV site for signs and symptoms of infection such as pain, swelling, redness and drainage. The facility's Midline Catheter Dressing Change policy dated 01/15/2004, revised 07/01/2012 included the following: The catheter insertion site is a potential entry site for bacteria that may cause a catheter-related infection .Sterile dressing change using transparent dressing is performed 24 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105577 If continuation sheet Page 7 of 12 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 105577 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/25/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Orlando 654 N Econlockhatchee Trail Orlando, FL 32825 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 0694 Level of Harm - Minimal harm or potential for actual harm hours post insertion or upon admission to facility .at least weekly .if the integrity of the dressing has been compromised. Further it read, When a transparent dressing is applied over a sterile gauze dressing it is considered a gauze dressing and is changed, every 24 hours post insertion, upon admission, every two days, and if the integrity of the dressing has been compromised (wet, loose or soiled). Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105577 If continuation sheet Page 8 of 12 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 105577 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/25/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Orlando 654 N Econlockhatchee Trail Orlando, FL 32825 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review the facility failed to discard expired food in the kitchen and in 2 of 3 nourishment rooms, (100 Hall, 200 Hall) and failed to wear a beard restraint during the food handling process. Findings: 1. On 03/22/2021 at 7:26 AM, a tour of the kitchen was conducted with the Certified Dietary Manager (CDM). The walk-in refrigerator had two pints of lactose free milk with an expiration date of 3/20/2021. There were ten pints of lactose free milk by the tray line with the same outdated expiration date. The CDM did not provide an explanation as to why the expired milk was still in the walk-in refrigerator and noted the lactose free milk by the trayline was going to be used for today's breakfast. Review of the United States Food and Drug Administration (FDA) Food Code 2017 documented, Manufacturer's use-by dates is not the intent of this provision to give a product an extended shelf life beyond that intended by the manufacturer. Manufacturers assign a date to products for various reasons, and spoilage may or may not occur before pathogen growth renders the product unsafe . the manufacturer's use-by date is its recommendation for using the product while its quality is at its best. Although it is a guide for quality, it could be based on food safety reasons. It is recommended that food establishments consider the manufacturer ' s information as good guidance to follow to maintain the quality (taste, smell, and appearance) and salability of the product. If the product becomes inferior quality-wise due to time in storage, it is possible that safety concerns are not far behind. Review of the United States Food and Drug Administration (FDA) Food Code 2017 documented, 3-201.13 Fluid Milk and Milk Products. Milk, . is susceptible to contamination with a variety of microbial pathogens such as Shiga toxin-producing Escherichia coli, Salmonella, and Listeria monocytogenes, and provides a rich medium for their growth . Dairy products are normally perishable and must be received under proper refrigeration conditions. 2. On 03/24/21 at 9:33 AM, an observation of the 200 Hall nourishment room with Certified Nursing Assistant (CNA) L was conducted. On the second row of the refrigerator door was a Styrofoam cup with lid and straw containing clear liquid. There was no date or name on the Styrofoam cup. The top shelf of the refrigerator had a white plastic bag tied up with a plastic container of food. There was no name and no date on the bag nor on the plastic container. CNA L said, I do not know if I'm supposed to throw away food or not, I don't know the facility's policy. She stated she had worked at the facility for eleven years. The facility's policy for labeling, dating and discarding food was taped to the outside of the freezer door in the 200 Hall nourishment room. CNA L said, I didn't know that was there. 3. On 03/24/21 at 9:42 AM, an observation of the 100 Hall nourishment room with Registered Nurse, (RN) M was conducted. The freezer had 1 box of frozen dinner of alfredo pasta with chicken and broccoli, one bag of frozen vegetables and one quart-sized frozen ice tea not labeled with name or date. RN M said, food should have a name and date on it. The facility's policy for labeling, dating and discarding food was taped to the outside of the freezer door in the 100 Hall nourishment room. RN M stated the night shift was responsible to check the nourishment rooms and discard any expired and unlabelled food items. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105577 If continuation sheet Page 9 of 12 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 105577 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/25/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Orlando 654 N Econlockhatchee Trail Orlando, FL 32825 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 On 03/24/21 at 6:00 PM, the CDM stated the kitchen staff checked the nourishment rooms on Monday, Wednesday and Friday and the CNA checked on the 11 PM-7 AM shift. Review of the Resident Personal Food policy read, . 2. Labeled and dated perishable items may be stored under refrigeration in the nursing units consistent with standards of food storage. Residents Affected - Some Review of the posted sign on the nourishment room refrigerator door read, Everything must be labeled with their name, room number and date . 11-7 Certified nursing assistant (CNA) will check for labeling and dating . Anything found in the refrigerator over 72 hours (3 days) or no date/ label will be discarded. No exception . 4. On 03/24/21 at 5:51 PM, [NAME] O was observed plating food on the trayline for the evening meal. [NAME] O had a full beard and was not wearing a beard net. He wore a blue surgical mask and his beard was sticking out on both sides of his mask. He said, yes it is the policy of the facility to wear hair coverings, which included facial hair while in the kitchen. He said, I'm wearing a mask, I just thought it was covering it all. The CDM verified it was the policy of the facility to wear hair coverings in the kitchen and that a blue surgical mask was not an acceptable alternative to the hair coverings. Review of the facility's Culinary Services Hair Restraint policy read, . Facial, or other exposed long body hair (i.e. arm hair) must be covered when in food preparation areas or while preparing food or around exposed food contact surfaces. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105577 If continuation sheet Page 10 of 12 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 105577 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/25/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Orlando 654 N Econlockhatchee Trail Orlando, FL 32825 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 Based on observation, interview, and record review the facility failed to implement a system for infection prevention and control to conduct required screenings upon entrance for symptoms of Coronavirus Disease 2019 (COVID 19), risk factors for transmitting the disease and recent exposure to the virus, prior to permitting vendors to enter the facility for 1 of 1 vendors observed entering the facility. Residents Affected - Few Findings: During a tour of the facility's kitchen on 03/22/21, at approximately 8:06 AM, a food vendor driver came into the kitchen, walked by the food preparation area to the other side of the kitchen by the reach-in cooler. He located the Certified Dietary Manager (CDM) to obtain signature for delivered items. The food vendor driver wore a cloth mask which had been pulled down under his chin and did not cover his nose and mouth. He stated he had not completed a screening questionnaire nor had his temperature checked as he entered the facility through the back kitchen door. He said no one was there to screen him. He said he did not perform hand hygiene as, he could not find a sink. The CDM acknowledged the food vendor driver had not been screened before entering the kitchen. The CDM said all vendors were to go to the front of the facility to be screened then they could come to the back to make deliveries. On 03/22/21 at 8:08 AM, the food vendor said, this was my first time to this location. He stated he delivered food items to other facilities and only had to drop off at the door and not go inside the facility. He verbalized that he had knocked at the back door but no one answered so he just came in. He acknowledged there was a sign at the back door directing vendors to check in at the front desk but he did not explain why he did not follow this direction. On 03/25/21 at 3:32 PM the Director of Nursing said she spoke to the vendors and there was a screening process before anyone could come into the facility. We tell them they have to show the facility one negative Polymerase Chain Reaction (PCR) test to be able to enter the building. She noted, kitchen vendors are not allowed to come into the building. We have the same process for every vendor. She said the process for kitchen vendors was to drop off the deliveries at the back door and kitchen staff would bring the deliveries in. She added that it was not acceptable for the food vendor to come into the kitchen. She acknowledged that for vendors to come into the facility they needed to have a COVID 19 test first. She said perhaps the food vendor provided the test to Human Resources. She stated due to recent COVID-19 outbreak of a staff member on Monday, March 22, 2021, the facility was limiting visitation to only compassionate caregivers. On 03/25/21 at 3:49 PM, the Human Resources Manager said they did not do COVID-19 test for vendors who only made deliveries. She stated that all vendors were required to come to the front entrance to be screened first. Screening questions included if vendors had traveled out of the country in the past 14 days, if they had any signs and symptoms such as fever, chills, nausea, vomiting, loss of taste or smell, if vendor had tested positive in past 14 days and if they had contact with anyone positive for COVID-19 in past 14 days. The vendors would then drive to the back and drop off the deliveries. She added they previously did screening near the back of the kitchen but they no longer did that. She noted all vendors should be directed to go to the front to get screened. Review of the Center for Disease Control, Interim Infection Prevention, and Control Recommendations for Healthcare Personnel During the COVID-19 Pandemic, Updated February 23, 2021 read, Screen and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105577 If continuation sheet Page 11 of 12 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 105577 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/25/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Orlando 654 N Econlockhatchee Trail Orlando, FL 32825 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 Triage Everyone Entering a Healthcare Facility for Signs and Symptoms of COVID-19 .symptom screening remains an important strategy to identify those who could have COVID-19 so appropriate precautions can be implemented . Post visual alerts at the entrance and in strategic places. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105577 If continuation sheet Page 12 of 12