Inspection·October 28, 2022

F 0636 Status: 43 days overdue Level of Harm - Potential for minimal harm Resident #5 Assessment Type: Quarterly Residents Affected - Many Assessment Reference Date: 8/31/22 Status: 42 days overdue Resident #6 Assessment Type: Quarterly Assessment Reference Date: 8/12/22 Status: 61 days overdue Resident #8 Assessment Type: Quarterly Assessment Reference Date: 8/19/22 Status: 54 days overdue Resident #9 Assessment Type: Quarterly Assessment Reference Date: 8/17/22 Status: 56 days overdue Resident #10 Assessment Type: Quarterly Assessment Reference Date: 9/9/22 Status: 32 days overdue Resident #11 Assessment Type: Quarterly Assessment Reference Date: 9/5/22 Status: 35 days overdue (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105562 If continuation sheet Page 2 of 13 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 105562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Ocala 2700 SW 34th St Ocala, FL 34474 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 0636 Resident #12 Level of Harm - Potential for minimal harm Assessment Type: Quarterly Assessment Reference Date: 9/18/22 Residents Affected - Many Status: 23 days overdue Resident #13 Assessment Type: Quarterly Assessment Reference Date: 8/11/22 Status: 61 days overdue Resident #14 Assessment Type: Quarterly Assessment Reference Date: 9/20/22 Status: 21 days overdue Resident #15 Assessment Type: Quarterly Assessment Reference Date: 9/20/22 Status: 22 days overdue Resident #23 Assessment Type: Quarterly Assessment Reference Date: 8/13/22 Status: 59 days overdue Resident #24 Assessment Type: Quarterly Assessment Reference Date: 8/14/22 Status: 59 days overdue Resident #25 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105562 If continuation sheet Page 3 of 13 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 105562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Ocala 2700 SW 34th St Ocala, FL 34474 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 0636 Assessment Type: Quarterly Level of Harm - Potential for minimal harm Assessment Reference Date: 8/17/22 Status: 55 days overdue Residents Affected - Many Resident #26 Assessment Type: Quarterly Assessment Reference Date: 8/15/22 Status: 58 days overdue Resident #27 Assessment Type: Quarterly Assessment Reference Date: 8/18/22 Status: 54 days overdue Resident #28 Assessment Type: Quarterly Assessment Reference Date: 8/18/22 Status: 55 days overdue Resident #29 Assessment Type: Quarterly Assessment Reference Date: 8/21/22 Status: 51 days overdue Resident #32 Assessment Type: Quarterly Assessment Reference Date: 8/24/22 Status: 49 days overdue Resident #33 Assessment Type: Quarterly (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105562 If continuation sheet Page 4 of 13 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 105562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Ocala 2700 SW 34th St Ocala, FL 34474 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 0636 Assessment Reference Date: 9/21/22 Level of Harm - Potential for minimal harm Status: 21 days overdue Resident #35 Residents Affected - Many Assessment Type: Quarterly Assessment Reference Date: 9/2/22 Status: 39 days overdue Resident #36 Assessment Type: Quarterly Assessment Reference Date: 8/28/22 Status: 44 days overdue Resident #37 Assessment Type: Quarterly Assessment Reference Date: 8/28/22 Status: 44 days overdue Resident #39 Assessment Type: Quarterly Assessment Reference Date: 9/11/22 Status: 30 days overdue Resident #40 Assessment Type: Quarterly Assessment Reference Date: 9/16/22 Status: 25 days overdue Resident #41 Assessment Type: Quarterly Assessment Reference Date: 9/16/22 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105562 If continuation sheet Page 5 of 13 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 105562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Ocala 2700 SW 34th St Ocala, FL 34474 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 0636 Status: 25 days overdue Level of Harm - Potential for minimal harm Resident #42 Assessment Type: Quarterly Residents Affected - Many Assessment Reference Date: 9/19/22 Status: 23 days overdue Resident #43 Assessment Type: Quarterly Assessment Reference Date: 9/19/22 Status: 22 days overdue Resident #48 Assessment Type: Quarterly Assessment Reference Date: 9/4/22 Status: 37 days overdue Resident #49 Assessment Type: Quarterly Assessment Reference Date: 9/10/22 Status: 31 days overdue Resident #50 Assessment Type: Quarterly Assessment Reference Date: 9/13/22 Status: 29 days overdue Resident #51 Assessment Type: Quarterly Assessment Reference Date: 9/16/22 Status: 26 days overdue (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105562 If continuation sheet Page 6 of 13 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 105562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Ocala 2700 SW 34th St Ocala, FL 34474 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 0636 Resident #59 Level of Harm - Potential for minimal harm Assessment Type: Quarterly Assessment Reference Date: 9/13/22 Residents Affected - Many Status: 28 days overdue Resident #109 Assessment Type: Quarterly Assessment Reference Date: 9/2/22 Status: 39 days overdue Resident #111 Assessment Type: Quarterly Assessment Reference Date: 8/20/22 Status: 53 days overdue During an interview on 10/26/2022 at 9:24 AM, the Minimum Data Set Coordinator Specialist confirmed the resident assessments had not been completed in a timely manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105562 If continuation sheet Page 7 of 13 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 105562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Ocala 2700 SW 34th St Ocala, FL 34474 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 0641 Ensure each resident receives an accurate assessment. 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 the assessment accurately reflected the resident's status for 1 of 3 residents sampled for discharge review, Resident #147. Residents Affected - Few Findings include: Review of Resident #147 progress note dated 8/5/2022 reads pt. [patient] in bed no apparent distress skin warm to touch, VS (vital signs) taken and recorded all WNL (within normal limits), pt. is able to voice his needs, denied pain and discomfort when asked, wife and son at bed side waiting for discharged info [information] pt went home with family about 12 noon. Review of Resident #147 Minimum Data Set (MDS) dated [DATE] read Section A0310, Type of Assessment: Discharge assessment-return not anticipated. Section A2000 discharge date [DATE], Discharge Status: Acute Hospital. Review of Resident #145 IDT (interdisciplinary team) Discharge summary dated [DATE] read B. Final Summary- Social Services: 10. Guest Family request discharge to home today 8/5/22. Baycare hh [Home Health] ordered per request. No equipment needed. During an interview on 10/26/2022 at 2:33 PM the Care Plan Specialist stated the resident was discharged to home but the assessment was marked discharged to acute hospital by mistake. During an interview on 10/26/2022 at 3:00 PM the Director of Quality Assurance stated the facility does not have a written policy for Minimum Data Set (MDS), the facility follows Resident Assessment Instrument (RAI). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105562 If continuation sheet Page 8 of 13 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 105562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Ocala 2700 SW 34th St Ocala, FL 34474 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 0695 Provide safe and appropriate respiratory care 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 ensure that a resident who needed respiratory care received such care consistent with professional standards of practice for 1 sampled resident, Resident #130, out of 28 residents who needed respiratory care. Residents Affected - Few Findings include: During an observation on 10/24/2022 at 3:28 PM, Resident #130 did not have any nasal cannula or mask to receive oxygen. During an interview on 10/24/2022 at 3:28 PM, Resident #130 stated, I am supposed to be on oxygen 24 hours. During an observation on 10/26/2022 at 8:25 AM, Resident #130 was receiving oxygen at 3.5 L/min (liters per minute) via N/C (nasal cannula). During an interview on 10/26/2022 at 8:25 AM, when asked about the dose of oxygen, Resident #130 stated, They gave me two. Review of Resident #130's medical records revealed the resident was admitted on [DATE] and readmitted on [DATE] with the diagnoses including osteomyelitis, gastrointestinal hemorrhage, anemia, chronic obstructive pulmonary disease, shortness of breath, atrial fibrillation, heart failure, hyperlipidemia, MRSA (Methicillin-resistant Staphylococcus aureus), presence of cardiac and vascular implant and graft, personal history of COVID-19 (Coronavirus Disease), GERD (Gastroesophageal reflux disease), essential hypertension, hypokalemia, muscle weakness, personal history of other malignant neoplasm of bronchus and lung, personal history of pulmonary embolism, personal history of transient ischemic attach (TIA), and cerebral infarction without residual deficits, presence of artificial knee joint bilateral, long term use of opiate analgesic, long term use of anticoagulants, encounter for fitting and adjustment of urinary device, dependence on supplemental oxygen. pain in right shoulder, dysphagia oropharyngeal phase, dysphagia pharyngoesophageal phase. Review of the physician orders dated 9/29/2022 for Resident #130 reads, Oxygen at 2 LPM [Liter Per Minute] via N/C or mask, every shift. Review of the physician orders dated 9/29/2022 for Resident #130 reads, Oxygen continuously every shift. Review of Resident #130's care plan dated 9/6/2022 reads, Focus: [Resident #130's name] has potential for difficulty breathing related to history of COVID-19, COPD, SOB (shortness of breath), history of lung cancer, and history of pulmonary embolism. Goals: [Resident #130's name] will be maintained at their respiratory baseline with a patent airway and unlabored respirations through next review . [Resident #130's name] will have no complications related to COPD, SOB, history of lung cancer, history of COVID-19, and history of pulmonary embolism through next review . Administer medications as ordered . O2 [oxygen] as ordered . Focus: [Resident #130's name] has oxygen therapy r/t [related to] SOB. Goals: [Resident #130's name] will have no s/sx [signs and symptoms] of poor oxygen absorption through the review date. Give medications as ordered by physician. Monitor/ document side effects and effectiveness Oxygen at 2 LPM via n/c continuous. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105562 If continuation sheet Page 9 of 13 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 105562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Ocala 2700 SW 34th St Ocala, FL 34474 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 0695 Level of Harm - Minimal harm or potential for actual harm During an interview on 10/26/2022 at 3:15 PM, Staff A, LPN (Licensed Practical Nurse), confirmed that the oxygen was at 3.5 L/min. She stated, I think it should be 2. During an interview on 10/26/2022 at 3:22 PM, the Director of Nursing (DON) stated that she expected the staff to follow physician orders for administration of oxygen. Residents Affected - Few Review of the policy and procedure titled Oxygen Administration revised in June 2017, last approved on 12/29/2021, reads, Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Oxygen is to be administered by licensed team members only . Procedure: Check physician order to determine prescribed rate and method of oxygen administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105562 If continuation sheet Page 10 of 13 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 105562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Ocala 2700 SW 34th St Ocala, FL 34474 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles. Findings include: An observation on October 25, 2022 at 9:10 AM of the 500 hall medication cart with Staff A, Licensed Practical Nurse (LPN) and Director of Nursing (DON) revealed 3 insulin pens were opened and undated in the cart. An envelope for Resident #141 in 503 W contained 1 Humulin 70/30 KwikPen with order date of 10/23/22 without an open date. Another envelope for Resident #141 contained an insulin pen, Humulin 70/30 KwikPen with order date of 10/13/22 without an open date. An envelope for Resident #149 in 505 D contained an insulin pen, Insulin Asparte Protamine 70/30 with an order date of 10/13/22 without an open date. The LPN was observed to uncap each pen and observe that each pen did have medication missing (photographic evidence obtained). During an interview on October 25, 2022 at 9:10 AM Staff A, LPN stated Insulin pens should be labeled with an open date, I should have checked the cart. This pen for [Resident #141 name] with an order date of 10/13/22 is used, the pen with order date 10/23/22 might be new due to the date, I am not sure. The pen for [Resident #149 name] has also been used. During an interview on October 25, 2022 at 9:30 AM with the DON stated my expectation is for the nurses to check dates for the insulin pens in the cart. Review of the Policy and Procedure titled 5.3 Storage and Expiration Dating of Medication, Biologicals, effective date of 12/01/07 and a revision date of 7/21/22 reads B. Facility should ensure that medications and biologicals are stored in an orderly manner in cabinets, drawers, carts, refrigerators/freezers of sufficient size to prevent crowding. 5. Once a medication or biologic package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened or opened. 5.1 Facility staff may record the calculated expiration date based on the date opened on the primary medication container. Review of Omni Care Insulin Storage Recommendation sheet reads Cartridges/Pens if Unopened a Humulin 70/30 pen 10 days. For opened Cartridges/Pens a Humulin 70/30 pen 10 days. Cartridges/Pens if Unopened Insulin Asparte Protamine 70/30 14 days, opened Asparte Protamine 70/30 14 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105562 If continuation sheet Page 11 of 13 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 105562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Ocala 2700 SW 34th St Ocala, FL 34474 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure medical records were accurately documented in accordance with accepted professional standards and practices for 1 of 3 residents reviewed, Resident #76. Findings include: During an observation on 10/24/2022 at 10:00 AM, Resident #76 was in her bed. The resident had scratches on her both arms from elbow to the tip of fingers. She had a band aid on the back of her left hand. During an interview on 10/24/2022 at 10:23 AM, Resident #76 stated, The scratches is from me. I am bad about that. They remind me not to scratch. I scratch them while asleep. During an observation on 10/25/2022 at 9:30 AM, Resident #76 was in her bed with no Geri sleeves. During an observation on 10/26/2022 at 1:25 PM, Resident #76 was in her bed with no Geri sleeves. During an observation on 10/27/2022 at 10:20 AM, Resident #76 was in her bed with no Geri sleeves. Review of Resident #76's medical records revealed the resident was admitted on [DATE] with the diagnoses including metabolic encephalopathy, neurosyphilis, enterocolitis due to clostridium difficile, adult failure to thrive, unspecified severe protein calorie malnutrition, other idiopathic peripheral autonomic neuropathy, spinal stenosis, other intervertebral disc degeneration, lumbar fusion, pressure ulcer of sacral region, stage 1, functional quadriplegia, weakness, muscle weakness, anemia, history of falling, colostomy status, encounter for attention to colostomy, long term use of antibiotics, other disturbances of skin sensation, major depressive disorder, recurrent, mild, essential (primary) hypertension, gastro-esophageal reflux disease without esophagitis, cognitive communication deficit, dysphagia, pharyngoesophageal, dysphagia, oropharyngeal, and hypocalcemia. Review of Resident #76's care plan dated 9/4/2022, reads, Focus: [Resident #76's name] has potential for alteration in skin integrity related to: fragile skin, right arm skin tear, bowel and bladder incontinence. Goals: Skin will remain intact through next review. Interventions: Geri sleeves to both arms. Review of Resident #76's admission MDS (Minimum Data Set) dated 9/4/2022 reads, Section C. Cognitive Patterns: C0500. BIMS [Brief Interview Mental Status] Summary Score: 10 [moderately impaired]. Review of Resident #76's Treatment Administration Record (TAR) showed Geri sleeves to both arms (ensure placement) every shift for prevention showed the resident had Geri Sleeves administered on Day, evening, night shifts from October 1 through October 24, 2022. Evening shift on October 25 was blank. On 10/26/2022 the sleeves were administered. The TAR does not show the code for refusal. During an interview on 10/27/2022 at 1:08 PM, Staff E, LPN (Licensed Practical Nurse), stated, She [Resident #76] wanted to have her arm breathe a little bit. I didn't have the opportunity to document that. She doesn't tolerate and refuses them. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105562 If continuation sheet Page 12 of 13 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 105562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Ocala 2700 SW 34th St Ocala, FL 34474 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview on 10/28/2022 at 2:15 PM, the Director of Nursing (DON) stated that the resident refused the sleeves, and the staff were not documenting the refusal of Geri sleeves correctly on the TAR. Review of the facility policy titled Charting and Documentation revised in December 2020 and last reviewed on 12/29/2021 reads, Purpose: The purpose of this procedure is to provide a complete account of the resident's care treatment, response to the care, signs, symptoms, etc., as well as the progress of the resident's care . Rules for Charting and Documentation: 1. Chart all pertinent changes in the resident's condition, reaction to treatments, medication, etc., as well routine observations. 2. Be concise, accurate, complete and use objective terms. Avoid brief, monotonous, and meaningless entries . 6. Refusals should be documented on the MAR (Medication Administration Record)/TAR. Event ID: Facility ID: 105562 If continuation sheet Page 13 of 13