Health inspection·August 16, 2023

F 0842 Level of Harm - Minimal harm or potential for actual harm Review of the TAR dated 5/1/2023 through 5/31/2023 for Resident #1 showed Buttocks: clean area, dry, apply xeroform and secure with barrier cream daily was not documented as completed on 5/13/2023, 5/14/2023, 5/15/2023, 5/16/2023, 5/17/2023, 5/18/2023, 5/19/2023, 5/20/2023, 5/22/2023, 5/23/2023, 5/24/2023 and 5/31/2023 on the day shift and 5/16/2023, 5/18/2023 and 5/25/2023 on the evening shift and 5/23/2023 on the night shift. Residents Affected - Few Review of the TAR dated 5/1/2023 through 5/31/2023 for Resident #1 showed Buttocks: clean area, dry, apply xeroform and secure with barrier cream daily was not documented as completed on Review of Resident #1's June TAR Buttock, clean area, dry, apply xeroform and secure with barrier cream daily was not documented as completed on/4 and 6/6/2023 evenings and 6/5/2023 on days. Review of the physician orders for Resident #1 dated 6/6/2023 reads, Wound care: Right Heel: clean ns (normal saline), pat dry, apply Nystatin powder, cover with isl drsg (island dressing) every day shift for skin tear for 14 days. Review of the TAR dated 6/1/2023 through 6/30/2023 for Resident #1 showed Wound care: Right Heel: clean ns (normal saline), pat dry, apply Nystatin powder, cover with isl drsg (island dressing) every day shift was not documented as completed on 6/8/2023, 6/9/2023, 6/10/2023, 6/11/2023 and 6/12/2023. 2. Review of the admission record for Resident #3 documented diagnoses to include anemia, chronic obstructive pulmonary disease, unspecified atrial fibrillation, and chronic pain syndrome. Review of the physician orders for Resident #3 dated 7/28/2023 reads, Clean right lower extremity with normal saline, allow to dry, apply Sorbact (type of dressing) to wound, cover with ABD (abdominal) pad and wrap with kerlix (gauze) change daily every shift for ulcers/lymphedema. Review of the TAR dated 8/1/2023 through 8/31/2023 for Resident #3 showed clean right lower extremity with normal saline, allow to dry, apply Sorbact to wound, cover with ABD pad and wrap with kerlix change daily was not documented as completed on 8/2/2023. Review of the physician orders for Resident #3 dated 7/28/2023 reads, Cleanse coccyx with normal saline, allow to air dry, apply honey to wound bed and cover with foam dressing change daily every day for stage 4 pressure. Review of the TAR dated 8/1/2023 through 8/31/2023 for Resident #3 showed cleanse coccyx with normal saline, allow to air dry, apply honey to wound bed and cover with foam dressing change daily every day for stage 4 pressure was not documented as completed on 8/2/2023. Review of the physician orders for Resident #3 dated 7/29/2023 reads, Lidocaine External Patch 4% (Lidocaine) Apply to RLE (Right Lower Extremity) topically at bedtime for pain. Review of the TAR dated 8/1/2023 through 8/31/2023 for Resident #3 showed Lidocaine External Patch 4% (Lidocaine) Apply to RLE topically at bedtime for pain was documented as administered on 8/9/2023 and 8/10/2023. Review of the physician orders for Resident #3 dated 8/2/2023 reads, Clean right lower extremity with NS, allow to dry, apply collagen sheet with silver to wound, cover with ABD pad and wrap with kerlix change daily every day shift for ulcers/lymphedema. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105571 If continuation sheet Page 2 of 3 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 105571 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Gainesville 227 SW 62nd Blvd Gainesville, FL 32607 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 Review of the TAR dated 8/1/2023 through 8/31/2023 for Resident #3 showed clean right lower extremity with NS, allow to dry, apply collagen sheet with silver to wound, cover with ABD pad and wrap with kerlix change daily was not documented as completed on 8/4/2023 and 8/14/2023. During an interview on 8/16/2023 at 1:38 PM Staff A, Licensed Practical Nurse (LPN) stated, We should be signing that wound treatments are completed. During an interview on 8/16/2023 at 1:50 PM the Director of Nursing (DON) stated, We should document all treatments and care we provide. There are blanks in the documentation, we are not following our policies related to documentation. Staff should always document that they completed the treatments. Review of the policy and procedure titled, Skin Care & Wound Management last revision date of July 2017 reads, Policy: 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. Procedure: Guideline for Skin Care and Wound Management include: monitor resident response to interventions for prevention and/or treatments and revise the care plan baseed on response, outcomes, needs and resident wishes. Page 4. Current standards of practice will be used for skin and wound management. Appropriate treatment protocols will be based upon Palm Garden Skin and Wound Guidelines and Lower Extremity Wound Care Guidelines in addition to Physician treatment orders. Physician orders obtained and documented on TAR (treatment administration record). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105571 If continuation sheet Page 3 of 3