Inspection·March 7, 2024

F 0658 Preparation: Facility should take all measures required by Facility policy and Applicable Law, including but not limited to the following: 3.2 Facility staff should only prepare medications for one resident at a time. 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: 105562 If continuation sheet Page 2 of 10 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 03/07/2024 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 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 ensure residents who are unable to carry out activities of grooming and personal hygiene receive these necessary services for 1 of 4 residents, Resident #12. Residents Affected - Few Findings include: Review of Resident #12's medical record documented the resident was admitted on [DATE] with a diagnosis of: cardiomegaly, mild protein-calorie malnutrition; nontraumatic hematoma of soft tissue; carpal tunnel syndrome, unspecified upper limb; lesion of ulnar nerve, right upper limb; history of falling; unspecified dementia; unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety; other idiopathic peripheral autonomic neuropathy; contracture, right hand. During an observation on 3/4/24 at 12:30 PM Resident #12 was sitting up in bed eating lunch. The fingernails of both resident's hands were long and dirty. The resident's hair was unkempt and matted. During an interview on 3/4/24 at 12:30 PM, Resident #12's son stated, I have to ask numerous times before his hair is washed. He can't ambulate and was not taken to be showered. He needs a Hoyer lift to be taken to the shower. There is no Hoyer lift for him to be showered. I have to keep on the staff to get personal care done. During an interview on 03/6/24 at 12:30 PM when Resident #12 was asked when he had his last shower, he stated, When I was at home. During an interview on 3/6/24 at 12:58 PM Staff F, Certified Nurse Assistant, (CNA) stated, We do not have the equipment for a long shower bed on the 800 Hall. Since COVID, we are not allowed to take the resident from the 800 Hall on a long shower bed down to the 100 Hall to the shower room, it's between the nourishment room and bathroom. On the 800 Hall the spa does not have a shower. A shower is in each of the resident's room and the long shower bed does not fit. Review of Resident #12's task sheet documented the resident had one shower in the past 30 days on 2/28/24. There were no resident refusals documented on the task sheet in the past 30 days. Bed baths were given on 2/8/24, 2/15/24, 2/19/24, 3/4/24, and 3/6/24. Not applicable was documented for 2/7/24, 2/9/24, 2/14/24, 2/27/24, 3/1/24, 3/2/24, and 3/6/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105562 If continuation sheet Page 3 of 10 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 03/07/2024 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 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 record review and interview the facility failed to ensure medications were managed in accordance with professional standards for 1 of 5 residents, Resident #111, reviewed for medications. Residents Affected - Few Findings include: Review of Resident #111's admission Record, date of initial admission 5/17/2023, documented the resident was admitted with diagnoses that included type 2 diabetes mellitus with unspecified complications. Review of Resident #111's physician order dated 1/6/2024 read, Lantus Subcutaneous Solution 100 Unit/ML [milliliter] (Insulin Glargine) Inject 30 unit subcutaneously two times a day for DM [diabetes mellitus]. Review of Resident #111's medication administration record (MAR) for the period of 2/1/2024-2/29/2024 documented the resident refused the Lantus medication 18 times, was not administered the medication 15 times coded as 9 Other/See Nurse Notes and was not administered the medication 12 times coded as 5 Hold/See Nurse Notes. Review of the MAR for the period of 3/1/2024-3/6/2024 documented Resident #111 refused the Lantus medication 4 times, was not administered the medication 2 times coded as 9 Other/See Nurse Notes and was not administered the medication 3 times coded as 5 Hold/See Nurse Notes. Review of Resident #111's medical record for the period of February 1, 2024, through March 5, 2024, did not contain documentation of Resident #111's physician or advance registered nurse practitioner being notified of Resident #111's medication refusals or of the medication not being administered as ordered by the physician. During an interview on 3/6/2024 beginning at 8:42 AM, the Director of Nursing (DON) verified Resident #111's medical record for the period of February 1, 2024 through March 5, 2024 did not contain documentation of Resident #111's physician or advanced registered nurse practitioner being notified of Resident #111's medication refusals or of the medication not being administered as ordered by the physician. The DON said the physician, or the advanced registered nurse practitioner should be notified when medications are refused or not administered as ordered by the physician. During an interview on 3/7/2024 beginning at 8:26 AM, Resident 111's Advanced Registered Nurse Practitioner stated, I don't recall getting notified of [Resident #111's name] medication refusals and medication not being administered as ordered. I would want to be notified. I would have stopped the Lantus. Had I been notified of [Resident #111's name] medication refusals and that the medication was not being administered as ordered, I would have looked for trends and might have stopped the Lantus. I would have used the information to make treatment decisions. Review of the policy and procedure titled, Change in a Residents Condition or Status, last reviewed 1/30/2024, read 1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been - A need to alter the resident's medical treatment significantly; Refusal of treatment, medications or meals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105562 If continuation sheet Page 4 of 10 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 03/07/2024 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview, and record review the facility failed to provide appropriate treatment and services to prevent possible urinary tract infections for 1 of 3 residents, Resident #67 reviewed for indwelling urinary catheters. Findings include: Review of the admission record documented Resident #67 was admitted to the facility with the following diagnoses: type 2 diabetes mellitus without complications, occlusion and stenosis of the left carotid artery, essential (primary) hypertension, atherosclerotic heart disease of the native coronary artery without angina pectoris (chest pain), seizures, pressure ulcer sacral region, hypothyroidism, heart failure unspecified, unspecified dementia without behavioral disturbances, and major depressive disorder. Review of Resident #67's physician orders dated 1/31/2024 read, Indwelling catheter #16 FR [French] per 10 ml [milliliter] DX [diagnosis] unstageable sacral wound. During an observation on 3/4/2024 at 12:33 PM Resident #67 was in bed, the urinary catheter drainage bag was resting on the floor attached to the bed with the urinary catheter tubing looped and the urine unable to drain into the urinary catheter drainage bag, the tubing was filled with urine. Review of Resident #67's care plan implementation date of 1/31/2024 read, At risk for complications r/t [related to] use of indwelling catheter for US [unstageable] sacral wound: anchor to thigh to decrease trauma, keep bag below level of bladder. During an observation on 3/5/2024 at 8:19 AM Resident #67 was observed in bed with the urinary catheter drainage bag attached to the bed and resting on the floor. There was urine within the urinary catheter tubing, the urinary catheter tubing was looped and the urine was unable to drain from the tubing into the urinary catheter drainage bag. During an observation on 3/6/2024 at 9:35 AM Resident #67 was observed resting in bed, the urinary catheter drainage bag and tubing were observed on the floor not attached to the bed. The urinary catheter tubing was looped on the floor with urine collected in the entire length of the tubing and unable to drain into the urinary catheter drainage bag. The urinary catheter bag did not have any urine in it. Resident #67 stated, My belly hurts and pointed to her lower abdomen. During an interview on 3/6/2024 at 9:36 AM Staff A, Certified Nursing Assistant (CNA) confirmed the catheter drainage bag was on the floor with looped tubing and was unable to drain into the urinary catheter drainage bag. During an observation on 3/6/2024 at 9:36 AM Staff A, CNA bent over, picked up the urinary catheter drainage bag from the floor, stood up and lifted the urinary catheter drainage bag to her eye level, with the urinary catheter drainage bag approximately two feet above the level of the resident's bladder. Staff A, CNA emptied the tubing while holding the catheter drainage bag above the level of the resident's bladder for approximately two minutes. Then Staff A, CNA attached the urinary catheter drainage bag to the bed, the bag was observed to be resting on the floor with the urinary catheter tubing looped on the floor. Staff A, CNA then donned gloves and emptied the urinary catheter drainage (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105562 If continuation sheet Page 5 of 10 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 03/07/2024 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few bag of 575 milliliters of amber colored urine. The drainage spout was observed touching the collection container. Staff A let go of the drainage spout and it was observed touching the floor while Staff A emptied the collection container in the bathroom. During an observation on 3/6/2024 at 9:42 AM Staff A, CNA performed incontinence care on Resident #67. Staff A assembled the supplies of warm soapy water, and washcloths. Staff A, CNA took a washcloth and wiped from Resident #67's back to front one time, took another washcloth, and wiped back to front and with the same washcloth wiped down the entire length of the urinary catheter and urinary catheter tubing to the urinary catheter drainage bag. During an interview on 3/6/2024 at 9:45 AM Staff A, CNA stated, [Resident #67's name] is a fall risk. She tries to get out of bed so the bag [urinary catheter drainage bag] will always be on the floor when we have the bed in the lowest position. I should not have put the catheter bag above the bladder. I didn't really know I was doing it, I got nervous. I didn't realize that I used the same washcloth to wipe down the tubing I shouldn't have. During an interview on 3/6/24 at 10:03 AM Staff B, Licensed Practical Nurse (LPN) stated, The catheter bag should not be on the floor and should be able to drain properly. It should not have loops in the tubing. Even with her bed in the lowest position we can maintain her tubing without kinks or loops in it, we just place it further away from her. During an interview on 3/6/24 at 3:12 PM the Director of Nursing (DON) stated, I just can't believe she did that. It is not acceptable to have the catheter above the level of the bladder and the catheter bags should not be on the floor. This is not acceptable practice. We do have training for pericare and catheter care upon hire and annually training is done. She should have known better. Review of the policy and procedure titled, Catheter Care Indwelling with an original date of 7/2023, last approval date of 1/30/2024 read, Purpose: To provide safe and proper care of a guest/resident with an indwelling catheter by evaluating elimination status, minimizing risk of bladder infection, and maintaining skin integrity. Procedure: 7. Wash hands and apply gloves. 8. Cleanse entire perineal area with soap and water or perineal wash, unless otherwise ordered. Females- separate labia and cleanse from center to thigh and front to back. 18. Position catheter and drainage bag below the level of the guest/resident bladder to facilitate flow of urine. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105562 If continuation sheet Page 6 of 10 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 03/07/2024 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 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 and interview, the facility failed to ensure the kitchen environment was kept clean and sanitary in accordance with professional standards. (Photographic evidence obtained). Residents Affected - Few Findings include: During the kitchen tour on 3/4/2024 at 9:15 AM with the Certified Dietary Manager (CDM), there was brownish water overflowing from a floor drain next to the food prep area in the main kitchen. During an interview on 3/4/2024 at 9:15 AM, the CDM stated, It has been like that for a few days, and I will have to have maintenance look at it. During a follow up visit of the kitchen on 3/5/2024 at 6:45 AM, brownish water was overflowing from the floor drain next to the food prep area in the main kitchen. During a follow-up visit to the kitchen on 3/6/2024 at 10:00 AM, there was brownish water overflowing from the floor drain next to the food prep area in the main kitchen. During an interview on 3/6/2024 at 10:00 AM, the CDM stated, The problem is that we could not get the top off the drain to clean it out, and maintenance has called the plumber. During an interview on 3/6/2024 at 10:20 AM, the Plant Maintenance Director stated, I did not know about the clogged drain in the main kitchen. There has not been any calls made to the plumber, and there has not been a work order for the kitchen since November 7th of 2023. Review of the policy and procedure titled, Kitchen Sanitation with the last review date of 1/30/24, read, Policy: The culinary staff shall maintain the sanitation of the dietary department through compliance with the posted comprehensive cleaning schedules. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105562 If continuation sheet Page 7 of 10 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 03/07/2024 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 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 prevent the possible spread of infection for residents on contact isolation, during hydration pass, and medication administration. Residents Affected - Some Findings include: 1) Review of the admission record for Resident #52 documented diagnosis to include acute kidney failure, type 2 diabetes mellitus, chronic kidney disease stage 3, personal history of transient ischemic attack (TIA) and cerebral infarction (a stroke) and essential (primary) hypertension. Review of the document titled, Lab results report for Resident #52 dated 3/3/2024 read, C. [Clostridium] Difficile Molecular [a highly sensitive and specific test for the presence of a toxin-producing C. difficile organism] result positive. 1st call attempt-3/4/2024 7:25 PM- unable to reach nurse. Critical result called to [Staff name] on 3/5/2024 9:35 AM by [laboratory staff name]. Review of Resident #52's physician orders dated 3/5/2024 read, Contact precautions every shift for C. Diff [Clostridium Difficile] for 14 days. During an observation of Resident #52's room on 3/5/2024 at 1:14 PM it showed isolation signage for special contact isolation on the doorway with isolation supplies outside the door. Staff E, Certified Nursing Assistant (CNA) was observed entering Resident #52's room without donning personal protective equipment (PPE), did not perform hand hygiene, and touched the resident's overbed table and bedrails with ungloved hands, picked up Resident #52's meal tray and exited Resident #52's room without performing hand hygiene. Staff E placed the meal tray in the food cart, did not perform hand hygiene, and went into Resident #95's room. Staff E removed the meal tray from Resident #95's overbed table and exited the room without performing hand hygiene and returned the meal tray to the meal cart. Staff E entered Resident #39's room without performing hand hygiene and removed the meal tray placing it in the meal cart. Review of the Special Contact precautions signage on Resident #52's door read, Before entering everyone MUST: perform hand hygiene with alcohol-based hand rub (ABHR) or soap and water, wear gown before entering and remove upon exiting, wear gloves, before entering and remove upon exiting. Before exiting, everyone MUST: Wash hands with soap and water. During an interview on 3/5/2024 at 1:19 PM Staff E, CNA stated I believe he is on isolation for C. Diff. I didn't gown or glove before going into his [Resident #52's] room to get his tray. I did not wash my hands after I removed his tray and went to the other two rooms. I should have done that. I did touch his overbed table and his lunch tray. 2) During an observation on 3/06/2024 at 10:27 AM Staff A, CNA was observed donning PPE without performing hand hygiene, entering Resident #52's room, went to the bedside, got Resident #52's Styrofoam cup from the bedside, and exited the room to get ice from the ice chest in front of the door. Staff A left the Styrofoam cup on the cart the ice chest was sitting on, removed gloves, without performing hand, and threw the gloves in a trash receptacle at the doorway. Without performing hand hygiene Staff A, CNA, obtained ice from the chest. Staff A, CNA donned gloves without performing hand hygiene, entered the resident's room, placed the ice filled cup at Resident #52's bedside, removed the PPE, did not perform hand hygiene, exited the room, and went to Resident #95's room to provide ice (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105562 If continuation sheet Page 8 of 10 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 03/07/2024 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 0880 water. Level of Harm - Minimal harm or potential for actual harm During an interview on 3/6/2024 at 10:32 AM Staff A, CNA stated, I did everything right. I got gloves and a gown like it says. I did not wash my hands. I knew that he was on isolation for C. Diff. I should have washed my hands, that's what the sign says, to use soap and water. Residents Affected - Some During an interview on 3/6/2024 at 3:12 PM the Director of Nursing stated, I expect staff to adhere to all contact precautions and to wash their hands. Review of the policy and procedure titled, Transmission Based Precautions with a last approval date of 1/30/2024 read, Transmission based precautions are used when the route of transmission is not completely interrupted using standard precautions alone and the pathogen may have multiple routes of transmission. Transmission based precautions are divided into: Contact precautions; droplet precautions, and airborne precautions. Precautions in place when symptomatic infections are not deemed colonized by the resident physician or center infection preventionist. 1. Contact precautions: wear PPE (personal protective equipment) gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident environment. A. Use when microorganisms are spread with direct or indirect contact with the resident or the resident environment. 3) During an observation of medication administration on 3/6/2024 at 8:39 AM with Staff C, Licensed Practical Nurse (LPN) for Resident #603, Staff C, LPN did not perform hand hygiene and prepared the resident's medications, donned gloves without performing hand hygiene, entered the resident's room and obtained a blood glucose. Staff C, LPN doffed the gloves without performing hand hygiene donned gloves, cleaned the needleless connector for less than 1 second of the resident's right single lumen peripherally inserted catheter (PICC), and did not allow the needleless connector to fully dry, and attached 0.9% normal saline and flushed the PICC line without verifying placement by checking for blood return. Staff C, LPN let the hub of the needleless connector come in contact with the resident's skin while she prepared the antibiotic and intravenous tubing line. Staff C, LPN attached the antibiotic without cleaning the hub of the needleless connector. Staff C, LPN doffed the gloves and left the resident's room returning to the medication cart to prepare another residents medication without performing hand hygiene. During an interview on 3/6/2024 at 8:44 AM Staff C, LPN stated, I didn't realize the connector was touching her skin. I should have cleaned it again. I do think I should have let the connector dry before I flushed it, I did not let it dry. We should wash our hands when we do meds and change gloves. During an observation of medication administration on 3/7/2024 at 5:59 AM Staff D, Registered Nurse (RN) was observed approaching the medication cart, did not perform hand hygiene and began to prepare medications for three residents, Residents #36, #17 and #138, at the same time. Staff D, RN brought the medications of the residents to each room. At 6:01 AM Staff D, RN entered Resident #36's room and without performing hand hygiene, assisted the resident up in bed, using the bed control to elevate Resident #37's head of the bed, and administered the residents medications. Staff D, RN picked up the medications for Residents #17 and #138, exited Resident #37's room without performing hand hygiene and entered Resident # 17's room. At 6:03 AM without performing hand hygiene; administered Resident #17's medications. Staff D, RN picked up Resident #138's medications, exited Resident #17's room without performing hand hygiene. At 6:06 AM Staff D, RN entered Resident #138's room without performing hand hygiene or donning gloves performed an accucheck to obtain a blood glucose level. Staff D, RN administered three units of insulin in Resident #138's left arm without cleansing the arm with a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105562 If continuation sheet Page 9 of 10 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 03/07/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some alcohol swab, performing hand hygiene, or donning gloves. Staff D, RN then administered Resident #138's oral medications and returned to the medication cart without performing hand hygiene. During an interview on 3/7/2024 at 6:10 AM Staff D, RN stated, I shouldn't have done that. I shouldn't have gotten all the meds [medications] at the same time. I shouldn't have gotten the accucheck without gloves on. I should have washed my hands. I should have used alcohol before I gave the insulin. Review of the policy and procedure titled, General Dose Preparation and Medication Administration with an effective date of 12/1/2007, and last approval date of 1/30/2024 read, Procedure: 2. Prior to preparing or administering medications, authorized and competent Facility staff should follow Facility's infection control policy (e.g., handwashing). Review of the policy and procedure titled, Hand Hygiene with a last approval date of 1/30/2024 read, Purpose: The purpose of this procedure is to provide guidelines to employees for proper and appropriate hand hygiene techniques that will aid in the prevention of the transmission of infections. When to wash hands: Appropriate fifteen (15) to twenty (20) second hand washing must be performed under the following conditions: 3. Before performing invasive procedures. 4. Before preparing and handling medications. 7. After contact with blood, body fluids, secretions, excretions, mucous membranes, or broken skin. 8. After handling items potentially contaminated with a resident's blood, body fluids, excretions or secretions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105562 If continuation sheet Page 10 of 10