Health inspection·February 29, 2024

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to ensure that resident assessments were transmitted in a timely manner for 2 of 3 residents sampled, Residents #44 and #46. Residents Affected - Few Findings include: Review of Resident #44's Minimum Data Set (MDS) Discharge Return Anticipated Assessment showed the assessment status was exported on 1/29/2024. Resident #44's assessment did not have a status of accepted. Review of Resident #46's Minimum Data Set (MDS) Discharge Return Not Anticipated Assessment status was exported on 1/30/2024. Review of Resident #46's assessment did not have a status of accepted. During an interview on 2/29/2024 at 10:06 AM, the MDS Coordinator stated, Those assessments [Resident #44's and Resident #46's] were done but did not transmit. We [the facility] do not have a policy for transmitting assessments but followed the MDS manual. Page 1 of 11 105571 105571 02/29/2024 Palm Garden of Gainesville 227 SW 62nd Blvd Gainesville, FL 32607

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 observation, interview, and record review, the facility failed to provide surgical wound care and treatment in accordance with professional standards of practice for 1 of 4 residents reviewed for skin conditions, Resident #77 (Photographic evidence obtained). Residents Affected - Few Findings include: During an interview on 2/26/2024 at 10:08 AM, Resident #77 stated, I had a mole removed last Thursday [2/22/2024]. On Saturday, the CNA [Certified Nursing Assistant] covered my site with gauze and transparent dressing. I don't think I'm supposed to have a dressing on there. During an observation on 2/26/2024 at 10:14 AM, Resident #77 had a transparent dressing with gauze under a transparent dressing on his right forearm. There was a dime sized circular area on the gauze of brownish drainage. Review of Resident #77's admission record revealed the resident had diagnoses including hypertension, osteoarthritis, heart failure, and stage 3 kidney disease (chronic). Review of Resident #77's dermatology visit note dated 12/28/2023 read, Impression/Plan: Neoplasm of Uncertain Behavior . Ddx [differential diagnosis] includes: Squamous Cell Carcinoma. Review of Resident #77's medical records revealed no physician order or treatment administration record entry for wound care on right forearm surgical site. During an interview on 2/27/2024 at 8:39 AM, Resident #77 stated, The CNA put it [the gauze and transparent dressing] on before my shower on Saturday [2/24/2024)], so I didn't get the sutures wet. No one has checked it at all. I don't think I'm supposed to have a dressing on there. During an observation on 2/27/2024 at 2:12 PM, Resident #77's right forearm had a tan colored large adhesive bandage covering the surgical site. During an interview on 2/27/2024 at 2:19 PM, Staff D, Licensed Practical Nurse (LPN), stated, I changed the dressing this morning because he [Resident #77] took the other one off. I cleansed it with normal saline, applied antibiotic ointment, then covered it with the dressing. During an interview on 2/28/2024 at 9:58 AM, Staff D, LPN, stated, I don't have a physician's order for [Resident #77's name] wound care, but it's basically the same thing as the other orders. I should have orders for wound care. There are no orders for care of his wound. During an interview on 2/28/2024 at 10:18 AM, the Director of Nursing (DON) stated, The expectation is that staff should review doctor's orders for wound care and treatment. If the dermatology office didn't give instructions for post-operative care, then the expectation is that staff call the dermatology office or the facility provider and get clarification. The nurse did not have orders for the care and should have. Review of the facility policy and procedure titled Skin Care & Wound Management with an approval date of 1/30/2024 read, 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 105571 Page 2 of 11 105571 02/29/2024 Palm Garden of Gainesville 227 SW 62nd Blvd Gainesville, FL 32607

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few infection, control pain and prevent development of pressure injury(s) unless the resident's clinical condition demonstrates that they were unavoidable . Procedure . Guidelines for Skin Care and Wound Management include . Skin inspection on a regular and ongoing basis to provide documentation and prompt interventions of any changes noted. Manage wound care using guidelines based upon current standards of practice . Inspection and Wound Management . The Skin Grid-Other will be completed upon identification of impaired skin at admission, at hospital return, at the time of a surgical wound, venous stasis wound, diabetic wound, burn, skin tear, laceration, abrasion, rash, MAD (moisture associated dermatitis) or any other significant skin condition is found . Current standards of practice will be used for skin and wound management. Appropriate treatment protocols will be based upon Palm Garden skin and Wound Care Guidelines and Lower Extremity Wound Care Guidelines in addition to Physician treatment orders. Physician treatment orders obtained and documented on the TAR (Treatment Administration Record). 105571 Page 3 of 11 105571 02/29/2024 Palm Garden of Gainesville 227 SW 62nd Blvd Gainesville, FL 32607

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to administer oxygen per physician order and according to professional standards of practice for 2 of 3 residents reviewed for respiratory care, Residents #36 and #112. Residents Affected - Few Findings include: 1. Review of Resident #36's admission record revealed the resident was admitted with the diagnoses including end stage renal disease, hypertensive heart and chronic kidney disease without heart failure with stage 5 chronic kidney disease, type 2 diabetes mellitus without complications, cerebral infarction, hemiplegia and hemiparesis affecting left non-dominant side, unspecified atrial fibrillation, essential primary hypertension, and major depressive disorder. Review of Resident #36's physician order dated 8/16/2023 read, Oxygen at 2 LPM [liters per minute] via N/C [nasal cannula] or mask every shift . Oxygen Continuously every shift. During an observation on 2/26/2024 at 10:10 AM, Resident #36 was receiving oxygen at 3 liters per minute via nasal cannula. During an observation on 2/28/2024 at 8:17 AM, Resident #36 was receiving oxygen at 3 liters per minute via nasal cannula. During an interview on 2/28/2024 at 8:17 AM, Resident #36 stated, I don't change that [the oxygen]. I can't reach it. During an interview on 2/28/2024 at 8:55 AM, Staff B, Registered Nurse (RN), confirmed that the oxygen was running at 3 liters per minute for Resident #36 and stated, All oxygen should be administered according to doctor's orders. During an interview on 2/28/2024 at 11:10 AM, the Director of Nursing (DON) stated, It is my expectation that nurses check oxygen daily and make sure it is running correctly. They should follow doctor's orders for running oxygen. 2. Review of Resident #112's admission record revealed the resident was admitted with the diagnoses including unspecified heart failure, essential primary hypertension and type 2 diabetes mellitus without complications. Review of Resident #112's physician order dated 12/5/2023 read, Oxygen at 3 LPM via N/C at bedtime for low sats [oxygen saturation] and as needed for low O2 [oxygen] sats < [less than] 90 during the day. During an observation on 2/26/2024 at 10:16 AM, Resident #112 was resting quietly in bed, receiving oxygen at 4 liters per minute. During an observation on 2/27/2024 at 8:10 AM, Resident #112 was resting in bed, receiving oxygen at 4 liters per minute. During an observation on 2/28/2024 at 7:43 AM, Resident #112 was resting in bed, receiving oxygen 105571 Page 4 of 11 105571 02/29/2024 Palm Garden of Gainesville 227 SW 62nd Blvd Gainesville, FL 32607

F 0695 at 4 liters per minute. Level of Harm - Minimal harm or potential for actual harm During an interview on 2/28/2024 at 8:55 AM, Staff B, RN, stated, It is at 4 liters and should be at 3 liters. We should check when we give meds [medications]. Residents Affected - Few Review of the facility policy and procedures titled Oxygen Administration with the last approval date of 1/30/2024 read, Procedure: 1. Verify physician's order to include, but not be limited to: flow rate, duration of use (PRN [as needed], continuous, etc.), parameters for monitoring oxygen saturation, as indicated . 14. Monitor oxygen flow rate and oxygen saturation, as ordered. 105571 Page 5 of 11 105571 02/29/2024 Palm Garden of Gainesville 227 SW 62nd Blvd Gainesville, FL 32607

F 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to ensure nurse staffing information was posted daily. Findings include: Residents Affected - Few During an observation on 2/26/2024 at 8:56 AM, the posted nurse staffing was dated 2/23/2024 (Photographic evidence obtained). During an interview on 2/28/2024 at 8:23 AM, the Director of Nursing stated, It is the responsibility of the weekend supervisor to post the staffing report daily. I was not aware the staffing report had not been posted daily. The facility does not have a policy for posting the staff report, but they follow the regulations. 105571 Page 6 of 11 105571 02/29/2024 Palm Garden of Gainesville 227 SW 62nd Blvd Gainesville, FL 32607

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 medications were securely stored in 1 of 3 residential units, Unit 300. Findings include: 1. During an observation on 2/26/2024 at 9:14 AM, Resident #55 was in her bed. A tube of Zinc Oxide Ointment was on Resident #55's bedside table. There was no nurse or other facility staff present in the resident's room. During an interview on 2/26/2024 at 9:14 AM, Resident #55 stated, I had bed sores and the cream is used for my bed sores. During an observation on 2/27/2024 at 8:03 AM, a tube of zinc oxide was on Resident #55's bedside table. There was no nurse or other facility staff present in the resident's room. Review of Resident #55's physician order dated 1/10/2024 read, Wound care to bilateral buttocks; apply zinc after each incontinent episode, every day and evening for prevention . Order Status: Active. Start Date: 1/10/2024. Review of Resident #55's physician orders revealed no order to self-administer medications. Review of Resident #55's Self Administration of Medication Consent Form dated 12/9/2023 and initialed by Resident #55, showed the resident had indicated, No, I do not want to exercise my right to self-administer by [Sic.] medications. During an interview on 2/28/2024 at 8:27 AM, the Director of Nursing stated that to her knowledge Resident #55 had not been assessed for self-administration of medication. She stated that Resident #55 had indicated she did not wish to self-administer medications on the self-administration of medication consent form dated 12/9/2023. During an interview on 2/28/2024 at 9:01 AM, Staff A, Licensed Practical Nurse/Unit Manager, stated the zinc oxide ointment found on Resident #55's bedside table should have been secured in the treatment cart and labeled for Resident #55. 2. During an observation on 2/27/2024 at 8:08 AM, Resident #344 was in her room. Resident #344 was holding two boxes of tubes of Nystatin External Cream 100000 unit/gram antifungal cream. There was no nurse or other facility staff present in Resident #344's room. During an interview on 2/27/2024 at 8:08 AM, Resident #344 stated the doctor had given her the cream to use on her buttocks. Review of Resident #344's physician order dated 2/27/2024 read, Nystatin External Cream 100000 unit/gm [gram] (Nystatin Topical), apply to periarea topically every shift for redness apply until healed; may use home supply . Order Status: Active. Start Date: 2/27/2024. Review of Resident #344's physician orders revealed no order to self-administer medications. 105571 Page 7 of 11 105571 02/29/2024 Palm Garden of Gainesville 227 SW 62nd Blvd Gainesville, FL 32607

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #344's Self Administration of Medication Consent Form dated 2/19/2024 and initialed by Resident #344, showed the resident had indicated, Yes, I would like to exercise my right to self-administer my medications. I understand that this right is subject to the results of the assessment of the care plan team. Review of Resident #344's care plan dated 2/19/2024 revealed no resident assessment for self-administration of medications. During an interview on 2/28/2024 at 9:07 AM, Staff A, Licensed Practical Nurse/Unit Manager, stated, [Resident #344's name] family brought the antifungal cream into the facility. I removed two tubes of the antifungal cream from [Resident #344's name] room but later discovered [Resident #344's name] had four tubes of the antifungal cream. I think her family probably brought it in the night before. [Resident #344's name] should not have the cream at beside, and it should have been in the cart. Staff A confirmed that Resident #344 had not been assessed for self-administration of medication. Review of Resident #344's progress note dated 2/28/2024 showed the progress note read, Self-Administration of Medication Notes: Medications found at bedside and removed. At this time, MD [Medical Doctor] prefers that resident not have Nystatin cream and powder at bedside due to overuse. Nursing will document the times resident requests the medication for 72 hours and then reevaluate to ensure proper use. Self-Administration Plan: Resident is not approved for self-administration of medications. Resident may not keep meds [medications] at bedside. Review of the facility policy and procedures titled Medications, Storage of with the last review date of 1/30/2024, showed the policy read, Purpose: The purpose of this procedure is to ensure the medications are stored in a safe, secure, and orderly manner. General Guidelines . 6. Compartments containing medications are locked when not in use. Trays or carts used to transport such items are not left unattended. (Compartments include, but are not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes.) Review of the facility policy and procedures titled Administration of Drugs with the last review date of 1/30/2024, showed the policy read, Key Procedural Points . 20. Medications should not be left at the bedside. Review of Self Administration of Medication Consent Form provided by the facility showed the consent form read, It is the policy of this facility that the resident has the right to self administer his or her own medication if the interdisciplinary team has determined that the practice is safe. The following criteria must be met: 1. Physician's orders for administration of medication must be on file at the facility (may be all or a specific drug); 2. The resident has signed a document stating his/her desire to self medicate; 3. The level of ability to identify medication, dosage, time, and to store properly has been determined as safe by the interdisciplinary team; 4. A safe storage place, plan for documentation and a method of accountability have been established; 5. If at any time the interdisciplinary team determines the practice is unsafe, the resident and physician will be notified. 105571 Page 8 of 11 105571 02/29/2024 Palm Garden of Gainesville 227 SW 62nd Blvd Gainesville, FL 32607

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 ensure food was safely stored, covered, labeled, and failed to ensure the equipment was cleaned in the areas of the kitchen and nourishment rooms. Findings include: A walk-through tour of the kitchen was conducted on 2/26/2024 at 9:16 AM with the Certified Dietary Manager (CDM). There were twelve large containers in the walk-in cooler that did not have identifying labels. There were eleven sandwiches and fourteen swirl cups in the reach-in cooler with no identifying labels. There was a pan of chicken noodle soup on the tray line at 9:22 AM with lunch times being 11:20 AM- 12:25 PM. During an interview on 2/26/2024 at 9:20 AM, the CDM stated that the containers did not have identifying labels and all leftover foods should be covered, labeled, and dated according to standards of practice. The CDM identified the twelve leftover food items in the walk-in cooler as pans of Salisbury steak, cabbage casserole, turkey, sweet potatoes, Italian sausages, hot dogs, gravy, ham, tomato soup, roast beef, beets, and marinara sauce. The CDM identified the eleven sandwiches as eight egg salad and three chicken salad sandwiches, and also identified eight swirl cups as chicken salad and six swirl cups as cottage cheese. During the follow-up tour of the kitchen on 2/27/2024 at 6:00 AM with the CDM, the drip tray on the gas stove had a buildup of black and tan grease and food debris, the microwave oven had food particles and rusty colored stains on the interior of the microwave, there were items opened and wrapped tightly on the spice tray with no identifying label, there was a large buildup of dust on the top of the reach-in cooler and reach-in freezer on the condenser motor and cords, and there was an opened bag of bread mix that was not properly closed or dated when opened in the dry storage. During an interview on 2/27/2024 at 6:00 AM, the CDM stated, The drip tray should have a new liner changed out weekly, the microwave should be cleaned daily, and maintenance department should be notified when cleaning is needed for the coils on top of reach-in cooler. I am not sure of what content in the wrapped item on the spice tray. The CDM unwrapped the item and found it to be chocolate chip cookies. The CDM stated that the wrapped item should have the date and identifying label and the mix in the dry storage room should have been properly closed and dated when opened. During an observation of nourishment rooms on 2/28/2024 at 8:00 AM, 2 of 3 nourishment rooms had microwaves that had a large buildup of food debris of tan, black, gold, and brown splotches and splatters on the interior sides and top of the microwaves. During an interview on 2/28/2024 at 8:10 AM, the CDM confirmed the microwave ovens were dirty with a buildup of food debris. Review of the document titled Kitchen Sanitation dated April 2017 and revised September 2018 read, Policy: The Culinary staff shall maintain the sanitation of the Dietary Department through compliance with the posted comprehensive cleaning schedules. 105571 Page 9 of 11 105571 02/29/2024 Palm Garden of Gainesville 227 SW 62nd Blvd Gainesville, FL 32607

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 maintain accurate and complete medical records for 1 of 2 residents reviewed for insulin administration out of a total of 6 residents reviewed for medications, Resident #104. Findings include: Review of Resident #104's admission record showed the resident was initially admitted on [DATE] with the diagnoses including type 2 diabetes mellitus, cerebral infarction (a stroke), and atrial fibrillation (an irregular heartbeat). Review of Resident #104's physician order dated 8/10/2022 read, Insulin Regular Human Solution Pen-injector 100 unit/ml [milliliter] inject s per sliding scale. Review of Resident #104's physician order dated 6/5/2023 read, Levemir FlexPen Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Detemir), Inject 20 units subcutaneously in the morning for DM [diabetes mellitus]. Review of Resident #104's Medication Administration Record (MAR) for January 2024 revealed no documentation of blood sugar level and administration of insulin on 1/9/2024 at 6:30 AM and on 1/23/2024 at 6:30 AM. Review of Resident #104's MAR for February 2024 revealed no documentation of blood sugar level and administration of insulin on 2/18/2024 at 6:30 AM. Further review revealed code 13 documented on 2/8/2024 for Levemir FlexPen 20 units subcutaneously. Review of the medication administration chart codes read, 13= does not require sliding scale insulin. During an interview on 2/27/2024 at 3:07 PM, Staff C, Licensed Practical Nurse (LPN), stated, I really don't think that I held this medication. I think that really is a documentation error. I would always give long-acting insulin and would check with the physician before I held a long-acting insulin. Yes, this was definitely a documentation mistake. During an interview on 2/28/2024 at 11:15 AM, the Director of Nursing (DON) stated, It was documented by mistake. I do expect accurate documentation for all medications. Nurses do not hold long-acting insulin for the short acting parameters. There are no parameters on the long acting insulins. I expect the nurses to follow our policies and document accurately when they give medications. There should be no blanks on the MAR. Review of the facility policy and procedures titled Administration of Drugs with the last review date of 1/30/2024 read, Policy: Residents shall receive their medications on a timely basis and in accordance with our established policies. Key Procedural Points . 7. Medications must be documented by the person administering the drugs immediately following the administration. The date, time administered, dosage, etc., must be documented in the electronic medical record and signed by the person administering the medication . Reporting and Documentation: 1. Document the following: date, time and initials. 105571 Page 10 of 11 105571 02/29/2024 Palm Garden of Gainesville 227 SW 62nd Blvd Gainesville, FL 32607

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 ensure staff performed hand hygiene during medication administration to help prevent the possible transmission of infection and communicable diseases in 3 of 6 observations for medication administration. Residents Affected - Few Findings include: During an observation on 2/28/2024 at 7:37 AM, Staff B, Registered Nurse (RN), exited a resident room after administering medications. Staff B returned to the medication cart and unlocked the cart and prepared medications for Resident #32 without performing hand hygiene. Staff B locked the medication cart, entered the resident's room and administered the medications. Staff B exited the resident's room and returned to the medication cart to prepare medications for another resident. During an observation on 2/28/2024 at 7:41 AM, Staff B, RN, exited a resident room after administering medications. Staff B returned to the medication cart and unlocked the cart and prepared medications for Resident #65 without performing hand hygiene. Staff B locked the medication cart, entered the resident's room and administered the medications. Staff B exited the resident's room and went to the nursing station. During an observation on 2/28/2024 at 8:26 AM, Staff B, RN, exited a resident room, returned to the medication cart, and began preparing medications for Resident #99 without performing hand hygiene. Staff B entered Resident #99's room and determined that the resident needed to be pulled up in bed prior to administering medications. Staff B returned to the medication cart and placed the medications in the medication cart. Staff B entered Resident #99's room, donned gloves without performing hand hygiene, and pulled Resident #99 up in the bed. Staff B doffed gloves without performing hand hygiene and returned to the medication cart and got the medications from the medication cart. Staff B returned to Resident #99's room and administered the medications without performing hand hygiene. During an interview on 2/28/2024 at 9:05 AM, Staff B, RN, stated, I should have washed my hands after I removed my gloves and before I prepared the residents' medications. Review of the facility policy and procedures titled Hand hygiene with the last review date of 1/30/2024 read, Purpose: The purpose of this procedure is to provide guidelines to employees for proper and appropriate handwashing techniques that will aid in the prevention of the transmission of infections . When to Hand Hygiene . 4. Before preparing or handling medications . 9. After removing gloves. 105571 Page 11 of 11