Health inspection·May 30, 2025

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record reviews the facility failed to ensure accurate Minimum Data Set (MDS) assessments for 3 of 8 residents, Residents #73, #103, and #87, reviewed for MDS assessments. Residents Affected - Few Findings include: 1) Review of Resident #73's physician order dated 5/3/2025 read, NPO [Nothing by Mouth] diet, Not applicable texture, NPO consistency. Review of Resident #73's speech therapy evaluation dated 5/8/2025 read Clinical Bedside Assessment of Swallowing: Dysphagia: Pt [patient] requiring suctioning of oral secretions. Unable to elicit volitional or reflexive swallow. At this time, not appropriate for PO [oral] trials due to poor oral manipulation, control of ability to initiate a swallow. Review of Resident #73's MDS admission dated 5/9/2025 read Section K0100. Swallowing Disorder, Check all that apply. No areas under this section were marked to acknowledge Resident #73 suffered a swallowing disorder. Review of Resident #73's physician order dated 5/5/2025 read provide suction every 1 hours as needed for retained oral secretions 5/5/2025. Review of Resident #73's electronic medical record dated 5/3/2025, documented by Advanced Practitioner Registered Nurse #1 read Order placed for bedside suction per daughter's request. Review of Resident #73's MDS admission dated 5/9/2025 read, Section O0110.D1. Suctioning: there was no entry documented/marked for suctioning. During an interview on 5/29/2025 at 11:00 AM, Staff B, Licensed Practical Nurse/Minimum Data Set Coordinator (LPN/MDSC) stated, It [suctioning] wasn't marked on the MAR [Medication Administration Record], so I didn't mark it. During an interview on 5/29/2025 at 3:00 PM the Registered Dietician (RD) stated, It [swallowing disorder] should have been marked. I usually wait until Speech has completed their evaluation, but their evaluation was complete on 5/8/2025. During an interview on 5/29/2025 at 2:00 PM, the Director of Nursing stated, I expect the MDS and care plans to be accurate and complete. 2) Review of Resident #87's MDS Evaluation dated 4/24/25 documented the following, Section C - BIMS [Brief Interview for Mental Status] Score - 03 [severe cognitive impairment]. Section N - N0415. High-Risk Drug Classes: Use and Indication: Antipsychotic the response was marked Yes. Review of Resident #87's medical diagnoses documented the following, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; Other: seizures. During an interview on 5/30/25 at 2:00 PM, Staff B, Licensed Practical Nurse (LPN) - Care Plan (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105571 If continuation sheet Page 2 of 20 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 05/30/2025 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Specialist, stated, I don't see that [Resident #87's name] was currently or previously receiving an antipsychotic medication. I marked that in error. During an interview on 5/30/25 at 2:45 PM the DON stated, Accuracy for the MDS evaluations is important. Having [Resident #87's name] MDS Evaluation marked 'yes' for receiving antipsychotic medications was another human error. I expect the correct medications and diagnoses to be documented. 3) During an observation on 5/27/25 at 2:11 PM, Resident #103 had a dual lumen, central venous catheter in his right upper chest. (Photographic evidence obtained) Review of Resident #103's medical diagnoses included the following, pneumonia, unspecified organism; methicillin resistant staphylococcus aureus infection as the cause of diseases classified elsewhere; dependence on renal dialysis. Review of Resident #103's MDS Evaluation dated 5/8/25 documented the following, Section C - BIMS 13, (cognition intact). Section I - I1700. Multidrug-Resistant Organism (MDRO) - the documented response was No, and I2000. Pneumonia - the documented response was, No. Section N - High risk medications: antibiotic. Section O - O0110-Special Treatments, Procedures, and Programs: documented No for A.2 - IV [intravenous]; No for H.1 - IV Medications; No for O1. IV Access; and No for O4. - Central. During an interview on 5/29/25 at 10:51 AM Staff B, LPN, Care Plan Specialist stated, We utilized the RAI [Resident Assessment Instrument] Manual as our policy for completing MDS evaluations. The reason pneumonia was marked as 'no' for [Resident #103'sname] during the MDS evaluation conducted on 5/8/25 was that he was not actively receiving treatment for it, and that the reason antibiotics were marked as a 'no' was because he was not ordered to receive them in the facility when he was admitted . The 'Central' in the section regarding IV access should have been marked 'yes,' and there is not an explanation for why multi-drug-resistant organisms (MDRO) was marked 'no.' During an interview on 5/29/25 at 2:00 PM, the DON stated, All newly admitted residents are reviewed at the Morning Meeting the following day, and the review includes the residents' orders and any new diagnoses. The MDS staff attend the Morning Meetings to hear the information in order to complete the MDS evaluations. The omission of [Resident #103's name] having a central venous catheter and the diagnosis of MRSA [methicillin-resistant Staphylococcus aureus]; MRSA is considered a MDRO [multidrug-resistant organism] and the mistake was due to human error. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105571 If continuation sheet Page 3 of 20 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 05/30/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interviews and record review, the facility failed to comply with the development and implementation of a comprehensive care plan regarding suctioning in 1 out of 3 residents. Resident #73. Residents Affected - Few Findings include: Review of Resident #73's physician order dated 5/5/2025 showed to read provide suction every 1 hours as needed for retained oral secretions 5/5/2025. Review of Resident #73's electronic medical record dated 5/3/2025, by Advanced Practitioner Registered Nurse #1 showed to read Order placed for bedside suction per daughter's request. During an interview on 5/29/2025 at 11:00 AM, Staff B, Licensed Practical Nurse/Minimum Data Set Coordinator, (LPN/MDS) stated if he [Resident #73] was receiving suctioning, it should have been care planned. During an interview on 5/29/2025 at 2:00pm, the Director of Nursing stated I expect the MDS' [Minimum Data Set] and care plans to be accurate and complete. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105571 If continuation sheet Page 4 of 20 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 05/30/2025 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 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 Based on interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain appropriate grooming and personal hygiene for 1 of 3 residents, Resident #61, reviewed for Activities of Daily Living. Residents Affected - Few Findings include: During an interview on 05/27/25 at 11:47 AM, Resident #61 stated, My shower days are Tuesdays, Thursdays, and Saturdays, but that I'm lucky to get a shower once a week. My preference is to have showers on my scheduled shower days. Review of Resident #61's Task List documentation for the period of 5/1/25 through 5/29/25 documented Resident #61 received showers on 5/1/25, 5/24/25, and 5/29/25, with no documentation of other bath or shower provided for the 30 days. During an interview on 5/30/25 at 9:05 AM Staff U, CNA (Certified Nursing Assistant) stated, We try to get each resident up and to the shower at least once a week. I'm not sure how often [Resident #61's name] receives a shower. We are supposed to document it in POC and in the shower book when the resident is bathed. I sometimes forget to document in one or the other location. During an interview on 5/30/25 at 9:20 AM Staff V, LPN stated, I changed the shower schedule for [Resident #61's name] from the 3-11 shift to the 7-3 shift because she [Resident #61] was not always getting her showers as scheduled. [Resident #61's name] was scheduled to receive a shower on Tuesday, Thursday, and Saturday. The Task List documentation was reviewed with Staff V, LPN for Resident #61. Staff V, LPN confirmed there was documentation of only three showers for Resident #61 in the last 30 days. The dates of the showers were confirmed to be documented on 5/1/25, 5/24/25, and 5/29/25. Review on 5/30/25 of the Documentation Survey Report for Resident #61, specifically for the Intervention/Task of Bathing/Showering, for May 2025, documented nine instances of missed opportunities for the administration of a bath or shower per Resident #61's preference and scheduled days for a shower. Review of Resident #61's MDS [Minimum Data Set] Evaluation dated 4/8/25 documented Section C: BIMS (Brief Interview for Mental Status) Score 14 (cognition intact). Section E: No behaviors were documented. Section F: C. F0400. Interview for Daily Preferences: How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? The response was documented as Very important; F0600. Daily and Activity Preferences Primary Respondent: Indicate primary respondent for Daily and Activity Preferences (F0400 and F0500) - The response was documented as, 1. Resident Section GG: GG0115. Functional Limitation in Range of Motion: Upper body extremities and Lower body extremities - the response is documented as, No impairment. All self-care activities are documented as, Independent, with the exception of shower/bathe self, which is documented as, Supervision or touching assistance. Review of Resident #61's Care Plan documented the following, Focus - Activities of Daily Living (ADL) Self-Care and/or mobility deficit. Needs assistance with ADL's; At risk of developing complications associated with decreased ADL self-performance related to: hypertension (HTN), generalized weakness, fatigue, decreased appetite, shortness of breath Date Initiated: 04/13/2023; Revision on: 04/13/2023. Goal Will maintain ADL self performance levels as evidenced by no decline in current level of functioning through next review date. Date Initiated: 04/13/2023; Revision on: 04/17/2025; Target (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105571 If continuation sheet Page 5 of 20 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 05/30/2025 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Date: 07/15/2025 Will have all ADL's complete by staff as needed. Date Initiated: 04/13/2023; Revision on: 04/17/2025; Target Date: 07/15/2025 Shower/bath-Supervision or touching assistance Date Initiated: 04/13/2023; Revision on: 04/15/2025. Review of the policy and procedure titled, Shower issued 7/2023, last reviewed 1/31/25, read, Purpose: To clean the skin and shampoo hair (as needed). To increase circulation. To exercise body parts/provide range of motion. To reduce tension. To promote comfort while maintaining safety and dignity. Procedure: . 28. Document any observations made during bathing. Observations may include, but are not limited to: Refusal of all or part of shower . 29. Provide the guest/resident with the opportunity to bathe according to guest/resident preference. 30. Document shower in the electronic medical record . Event ID: Facility ID: 105571 If continuation sheet Page 6 of 20 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 05/30/2025 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 treatment and care was provided in accordance with professional standards of practice for a central venous catheter for 1 of 3 residents, Resident #103, observed for intravenous (IV) catheter care and medication administration practices. Residents Affected - Few Findings include: During an observation on 5/27/25 at 2:11 PM, Resident #103 had a dual lumen, central venous catheter in his right upper chest with a dressing dated 5/1/25. The catheter insertion site was visible, the dressing was clean, dry, and intact. (Photographic evidence obtained) During an interview on 5/27/25 at 2:11 PM, Resident #103 stated, The last time I was in the hospital they put in the catheter for antibiotics. Since I've returned to the facility, a nurse had said that the dressing needed to be changed, but the dressing has not been changed. Review of Resident #103's medical record documented the resident was most recently admitted on [DATE] with medical diagnosis to include pneumonia, unspecified organism; methicillin resistant staphylococcus aureus Infection as the cause of diseases classified elsewhere; dependence on renal dialysis Review of Resident #103's physician orders did not have documentation of an order for central IV-line dressing changes. Review of Resident #103's Initial Plan of Care Summary (PIC/IPOC), dated 5/1/25, documented that the resident had a percutaneously inserted central catheter (PICC) line. During an interview on 5/28/25 at 3:17 PM, Staff A, LPN stated, I have flushed [Resident #103's name] central venous catheter, as it was ordered to be done daily. I was not sure whether [Resident #103's name] had an order for a dressing change for his central venous catheter, and an order did not pop up in the computer to complete [a dressing change]. I didn't have time to investigate [for an order]. The admitting nurse should have identified whether there was an IV catheter and that it needed an order for a dressing change. During an interview on 5/29/25 at 9:24 AM, Staff B, LPN stated, I worked with [Resident #103's name] on the 11p-7a shift [11:00 PM - 7:00 AM] on 5/26/25. I have been giving his IV Vancomycin on the 3-11 shift [3:00 PM to 11:00 PM]. I looked at the IV site and spoke with the resident about it. I recall that the dressing had a five on it, but I don't recall the full date. I believe the policy for IV dressing changes was for them to be done every seven days. If I identified a dressing was older than seven days, I would go back and check the orders [for frequency of dressing changes], and if it is supposed to be changed, I would report it to my supervisor and contact the doctor for orders. During an interview on 5/29/25 at 9:39 AM, the Medical Director stated, I don't recall being contacted on or around 5/1/25 regarding [Resident #103's name] orders upon readmission from the hospital. I was aware that the resident had a central vascular catheter and intravenous (IV) antibiotics, but I don't recall the nurse discussing any orders for the IV catheter. When residents come back from a hospitalization I usually discuss the medications with the nurse and the orders for IV catheters, such as dressing changes, are in the nursing realm, as IV dressing changes are a nursing standard. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105571 If continuation sheet Page 7 of 20 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 05/30/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 5/29/25 at 9:50 AM, Staff C, LPN stated, I am familiar with [Resident #103's name]. I worked with him within the past two to three weeks, but I can't recall the dates. I didn't administer anything to [Resident #103's name] through a central intravenous catheter and I don't recall whether he had a central IV catheter. I believe the policy for IV dressing changes was every seven days, and that as an LPN I would not change the dressing. If I observed that the dressing had been in place for greater than seven days, I would be expected to report it [to her supervisor]. During an interview on 5/29/25 at 9:55 AM the Director of Nursing (DON) When a resident is admitted the nurse completes an admission packet. The nurse would enter the medications and call the doctor to confirm the orders. A head-to-toe assessment would be expected to be done, which includes documentation of a skin check and documentation of any IVs, tubes, or drains. The nurse is expected to review the discharge summary from the hospital and would look to see if a specific type of IV line is mentioned. The expectation is the nurse who admitted [Resident #103's name] would have obtained dressing change orders, and that IV dressings were changed weekly, or more often if the dressing had lifted, was torn, or was soiled. Review of Resident #103's Care Plan, updated on 5/2/25, documented Focus - IV therapy/potential for complications related to PICC line. Date Initiated: 05/02/2025. Goal - IV site will remain free from S/S [signs/symptoms] of infection. Date Initiated: 5/02/2025 Target Date: 06/04/2025. Interventions - Change dressing to IV site per orders/facility policy. Date Initiated: 05/02/2025 Review of Resident #103's evaluation documented on the Clinical admission form dated 5/1/25 under the section for IV catheters/access, there was no documentation of a central venous catheter. Review of the Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (3008) provided to the facility from the discharging hospital documented, Section V. Treatment Devices, IV/PICC/Portacath Access - Date Inserted 5/1/25. Type: powerline. Review of the policy and procedure titled, Central Vascular Access Device (CVAD) Dressing Change, with an effective date of 10/2005, read, Considerations - 1. Central vascular access devices (CVADs) include: . 1.4 Implanted venous ports. 2. The catheter insertion site is a potential entry site for bacteria that may cause a catheter-related infection . Guidance - 1. Perform sterile dressing changes using Aseptic Non Touch Technique (ANTT): 1.1 Upon admission 1.1.1 If transparent dressing is dated. clean, dry, and intact, the admission dressing change may be omitted and scheduled for 7 days from the date on the dressing label . 1.2 At least weekly . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105571 If continuation sheet Page 8 of 20 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 05/30/2025 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. 2) Review of Resident #62 Omnicare Consultation Report dated 4/18/2025 read, Recommendation: Please attempt a gradual dose reduction to Abilify 1 mg once daily. The consultation report did not have a physician signature, or a rationale only documented MD [Medical Doctor] refused. Review of Resident #62 physician order dated 4/17/2025 read, Aripiprazole Tablet 2 mg give 1 tablet by mouth in the morning for depression. During an interview on 5/29/2025 at 3:53 PM Medical Doctor #1 stated, [Resident #62's name] has severe depression and is doing fairly well with the medication. After talking to the resident, we decided to keep the medication. Sometimes the facility requires a rationale, but it is typically more complicated. Usually, the nurses will drop the recommendation in my book, and I will review them. During an interview on 5/30/2025 at 2:51 PM the Director of Nursing stated, [Resident #62 name] consultation report should have been signed and a rationale should have been provided. Based on interview and record review, the facility failed to ensure documentation of physician/prescriber's rationale for declination of pharmacist's recommendations for 3 of 5 residents, Residents #99, #111, and #62, reviewed for unnecessary medications. Findings include: 1) Review of the Medication Regimen Review recommendations for Resident #99 dated 4/22/2025 read [Resident #99's name] 's PRN [as needed] orders below have not been used within the previous 60 days: 1. Artificial. Tears 2. Loperamide 3. Ondansetron 4. Tramadol. Recommendation: Please consider discontinuing due to lack of use. Physician's Response: I decline the recommendation(s) above and do not wish to implement any changes due to the reasons below. The rationale for declining the recommendations was not documented in the resident's record. 2) Review of Medication Regimen Review recommendations for Resident #111 dated 2/26/2025 read, Recommendation: Please decrease citalopram to 20 mg [milligrams] daily or consider alternative therapy. Physician's Response: I decline the recommendation(s) above and do not wish to implement any changes due to the reasons below: Psych follows was documented by the physician 3/4/2025. There was no follow up psych documentation for the rationale for declining the recommendations documented in the resident's record. Review of the Medication Regimen Review recommendations for Resident #111 dated 2/26/2025 read Recommendation: Please discontinue Amitriptyline. Physician's Response: I decline the recommendation(s) above and do not wish to implement any changes due to the reasons below: Psych follows was documented by the physician 3/4/2025. There was no follow up psych documentation for the rationale for declining the recommendations documented in the resident's record. During an interview on 5/29/2025 at 1:30 PM, the Director of Clinical Services (DCS) stated The process is the MRR [Medication Regimen Review] is printed out by medical records and given to the DCS, who forwards them to the Unit Managers. The Unit Managers give them to the physicians to directly address the issues and then we review them. The physician should always document the rationale on the form and in the resident record. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105571 If continuation sheet Page 9 of 20 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 05/30/2025 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 5/30/2025 at 11:00 AM, Medical Doctor #2 stated Just because they recommend to discontinue something because it hasn't been used in 60 days doesn't mean he won't need it eventually. I'm not going to discontinue it and turn around and have to re-order it because he needs it. I'll document that on the form from now on. During an interview on 5/30/2025 at 1:00 PM, Advanced Practitioner Registered Nurse (APRN) #1, stated If there is anything involving psych, they have GDR meetings weekly, so all pharmacy recommendations involving psych medication management should be addressed by the Director of Clinical Services, nursing and psychiatric services. Review of the policy and procedure titled, Medication Regimen Review with a last review date of 1/31/2025, read 9. Facility should encourage physician/prescriber or other responsible parties receiving the MRR and the director of nursing to act upon the recommendations contained in the MRR. 9.1 For those issues that require physician/prescriber intervention, facility should encourage physician/prescriber to either accept and act upon the recommendations contained within the MRR or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected, as outlined in the State Operations Manual Appendix PP. 9.2. The attending physician should document in the resident's health record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. 9.2.1. If the attending physician/prescriber has decided to make no change in the medication, the attending physician should document the rationale in the residents' health record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105571 If continuation sheet Page 10 of 20 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 05/30/2025 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 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 stored in accordance with currently accepted professional principle for 1 of 3 hallways reviewed for secured medication. Findings include: 1) During an observation on 5/27/2025 at 10:17 AM of Resident #71 it showed the resident was lying in bed. CeraVe itch relief moisturizing cream, vapor rub, Benadryl extra strength cream, and arthritis cream which contained 10% Trolamine Salicylate was on top of the nightstand. (Photographic evidence obtained) Review of Resident #71's medical record did not document an order or an assessment the resident was safe to self-administer medications. 2) During an observation on 5/27/2025 at 10:28 AM of Resident #53 it showed the resident was lying in bed. Nystatin Cream was observed on top of the nightstand. (Photographic evidence obtained) Review of Resident #53's medical record did not document an order or an assessment the resident was safe to self-administer medications. 3) During an observation on 5/27/2025 at 10:41 AM of Resident #99 it showed the resident was lying in bed. There was a bottle of Clear Eyes, eye drops on top of the bedside table. (Photographic evidence obtained) During an interview on 5/27/2025 at 10:41 AM Resident #99 stated, I do that [pointing to the bottle of eye drops] twice a day, the nurses are supposed to do it for me. Review of Resident #99's medical record did not document an order or an assessment the resident was safe to self-administer medications. During an interview on 5/30/2025 at 9:59 AM Staff M License Practical Nurse stated, [Resident #71's name], [Resident #53's name], and [Resident #99's name] do not have orders for self-administration. Medication should not be left in their rooms unattended. I know that [Resident #71's name] family will bring medications often and leave them in the room. During an interview on 5/30/2025 at 11:01 AM the Director of Nursing (DON) stated, Medication should not be unattended. There should be an assessment but [Resident #53's name], [Resident #71's name], and [Resident #99's name] do not have one at this time. Review of the policy and procedure titled Self Administration of Medications with a last review date of 1/31/2025 read, Procedure: 1. Facility should comply with facility policy, applicable law and the State Operations Manual with respect to resident self-administration of medications. 9. Facility should provide a secure compartment for storage of such medications in accordance with facility policy. 9.1 The medication storage compartments should be located in the resident's room so that another resident is not able to access the medications. 9.2 The storage compartment should be locked when (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105571 If continuation sheet Page 11 of 20 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 05/30/2025 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 0761 not in use. Level of Harm - Minimal harm or potential for actual harm 4) During an observation on 5/29/25 at approximately 4:05 PM, Staff E, Licensed Practical Nurse (LPN) attempted to administer three oral medications to Resident #107, but the resident refused the medications. Staff E, LPN set the medication cup containing the three pills on the medication cart and walked away from the cart, leaving the medications unattended. Residents Affected - Few During an interview on 5/29/25 at 4:10 PM, Staff F, Registered Nurse, (RN) stated, She [Staff E, LPN] should have at least locked them [the three medications] in the med cart until she had time to deal with them. During an interview on 5/29/25 at approximately 5:20 PM Staff E, LPN stated, I was flustered by answering questions [asked by this writer] and that was what caused me to leave [Resident #107's name] medications unattended. I know I should not have left the medication unattended. Review of the policy and procedure titled, 5.3 - Storage and Expiration Dating of Medications and Biologicals, with an effective date of 12/1/07, and last reviewed 1/2025, read, Applicability: Policy 5.3 sets forth the procedures relating to the storage and expiration dates of medications, biologicals, syringes, and needles. Procedure . 5. Facility should ensure all medication and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible to residents and visitors . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105571 If continuation sheet Page 12 of 20 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 05/30/2025 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 - Some 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 complete and accurately documented medical records for 5 of 8 residents, Residents #28, #32, #62, #97, and #119 reviewed for medication management, 2 of 6 residents, Residents #99 and #111 reviewed for mood and behavior, 1 of 3 residents, Resident #103 reviewed for intravenous therapy, and 1 of 3 residents, Resident #136, reviewed for discharge. Findings include: 1) Review of Resident #97's physician order dated 5/5/2025 read, Basaglar Kwikpen Solution Pen-Injector 100 UNIT/ML [milliliter] [insulin Glargine] inject 10 unit subcutaneously in the morning for diabetes. Review of Resident #97's physician order dated 5/5/2025 read, Insulin Lispro [NAME] KwiwPen Subcutaneous solution Pen-Injector 100 UNIT/ML [Insulin Lispro] inject as per sliding scale: If 0-150= 0 units, 151-200=2 units, 201-250= 4 units, 251-300= 6 units, 301-350=6 units, 351-400=10 units; 401+ Notify MD [Medical Doctor] subcutaneously before meals for diabetes. Review of Resident #97's Medication Administration Record (MAR) for the Month of May 2025 for Insulin Lispro revealed a blank entry on 5/04/2025 at 0630 [6:30AM]. Review of Resident #97 MAR for the Month of May 2025 for Basaglar Kwikpen 10 units revealed blank entries on 5/9/2025 and 5/13/2025. During an interview on 5/29/2025 at 12:00 PM the Director of Nursing (DON) stated, I spoke to [Staff F, Registered Nurse's name (RN)] and she stated [Resident 97's name] refused the insulin coverage due to the blood glucose level but she forgot to document it in the medication administration record. I also spoke to [Staff G, License Practical Nurse's name (LPN)] and [Resident #97's name] was running less than 150 and did not need coverage but does not know why she did not document it. During an interview on 5/29/2025 at 1:38PM Staff F, RN stated, The blood sugar was low and [Resident #97's name] refused both days on 5/9/2025 and on 5/13/2025 the blood sugar was low. I called the doctor to notify him, and I did not give the insulin. I forgot to write a progress note normally I will write a note in the system. During an interview on 5/29/2025 at 1:33 PM Staff G, LPN stated, I forgot to document that day. [Resident #97's name] was running low I cannot remember the blood sugar level but it was less than 150. [Resident #97's name] did not require insulin coverage normally she runs low. I went to get her a snack and in the exchange forgot to document. 2) Review of Resident #119's physician order dated 2/24/2025 read, Insulin Aspart 100 UNIT/ML inject 11 units subcutaneously three times a day for DM2 [Diabetes Mellitus Type 2] hold for glucose less than 100. Review of Resident #119's MAR for the month of May 2025 documented on 5/10/2025 for Insulin Aspart at 7:30 AM no blood glucose value was documented. Coded as 9 at 2100 [9:00 PM] was checked off as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105571 If continuation sheet Page 13 of 20 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 05/30/2025 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 given but no blood glucose value was documented. On 5/14/2025 at 2100 [9:00 PM] blood glucose value was documented as 94 and the insulin was checked off as administered. Review of Resident #119's physician order dated 5/11/2025 read, Insulin Glargine Subcutaneous Solution [Insulin Glargine] Inject 50 units subcutaneously at bedtime for DM. Residents Affected - Some Review of Resident #119's MAR for the month of May 2025 documented for Insulin Glargine 50 units documented on 5/17/2025 HS [hour of sleep] coded 5. During an interview on 5/29/2025 at 4:52 PM Staff R, LPN, stated, The system will not allow you to move forward if you don't document. I might have been quick to click to check it off, but she [Resident #119] did not get the insulin. I always follow the parameters. During an interview on 5/29/2025 at 4:50 PM Staff S, LPN, stated, I don't recall if I held it or not [the insulin]. Normally I would call the provider if I have a question or concern with medication. 3) Review of Resident #28's physician order dated 5/14/2025 read, Tresiba FlexTouch Subcutaneous Solution Pen-injector 100 UNIT/ML [Insulin Degludec] Inject 10 unit subcutaneously in the morning for DM2. Review of Resident #28's MAR for the month of May 2025 documented on 5/2/2205 at HS coded 9. Review of Resident #28's progress noted dated 5/2025 read, bg [Blood Glucose] was 63. During an interview on 5/30/2025 at 1:09 PM the Advance Practice Registered Nurse #1 (APRN #1) stated, Normally staff will contact me if they have a question regarding insulin administration or blood sugars. I have no concerns regarding staff holding medication when they should. I get many calls, and I am not able to remember specific dates. 4) Review of Resident #62's physician order dated 4/17/2025 read, Oxycodone HCL [hydrochloride] capsule 5 mg [milligrams] give 1 tablet by mouth every 6 hours as needed for moderate to severe pain level 6-10. Review of Resident #62's MAR for the month of May 2025 for Oxycodone 5 mg documented medication was given on 5/5/2025 at 2015 [8:20 PM] for a pain level of 4, 5/11/2025 at 2054 [8:54 PM] for a pain level of 4, 5/12/2025 at 2032 [8:32 PM] pain level of 5, on 5/14/2025 at 1411 [2:11 PM], and at 2249 [10:49 PM] pain level of 5, and on 5/15/2025 at 2201 [10:01 PM] pain level of 5. During an interview on 5/30/2025 at 9:29 AM Staff H, RN stated, [Resident #62's name] is always in pain. His pain is never lower than 9 or 10. It was a typo when entering the pain level in the record. During an interview on 5/30/2025 at 11:00 AM the DON stated, I am glad the nurses remember [Resident #62's name] pain levels, but I believe it was more a human error and typing to fast in the key board. During an interview on 5/30/2025 at 2:10 PM Staff L, LPN, stated, Usually his pain is 6 or 7 could have been I entered the wrong pain level. It could have been a distraction, I do not recall. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105571 If continuation sheet Page 14 of 20 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 05/30/2025 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 - Some Review of the policy and procedure titled General Dose Preparation and Medication Administration with a last review date of 1/31/2025 read, Procedure: .5.2 Facility staff should verify that the medication name and dose are correct when compared to the medication order on the medication administration record .6. After medication administration, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: 6.1 Document necessary medication administration/treatment information (e.g., when medications are opened, when medications are given, injection site of a medication, if medications are refused, PRN [as needed] medications, application site) on appropriate forms. Review of the policy and procedure titled, Charting and Documentation with a last review date of 1/31/2025 read, Purpose: The purpose of this procedure is to provide a complete, accurate, readily accessible and systematically organized medical record. The medical record will reflect a resident's progress toward achieving their person-center plan of care objectives, goals, and improvement and/or maintenance of their clinical functional, mental and psychosocial status. Guidelines, Effective Documentation practices include but are not limited to: use only appropriate terminology and abbreviations. 8) Review of Resident #136's nurses note dated 2/28/25 read, Resident discharged home with husband and home health care. Review of physician orders did not provide for documentation of an order for Resident #136 discharge. During interview on 5/29/25 the DON stated, I received a verbal order for the resident to discharge [Resident #136] and it was written in her progress note not in orders. During interview on 5/30/25 Staff N, LPN, Unit Manager stated, Social Services starts the process of a discharge. The order is obtained from the physician and put in the orders section of the chart. Review of the policy and procedure titled, Transfer and Discharge Requirements F622 and F 623 last review date of 1/31/25 read, Purpose: To ensure that the center follows the requirements under which a guest/resident may be transferred or discharged from the center, the documentation that is required to be included in the medical record, who is responsible for the documentation and the information that is required to be provided to the receiving provider for a transfer or discharge. Procedure: d. The resident's attending physician or the medical director of the center must sign any notice indicating a medical reason for transfer or discharge. i. ARNP or PA [Physician Assistant] may sign. ii. Fax signature is acceptable. 5) Review of resident #32's physician orders dated 12/05/24 read, Midodrine HCL oral tablet 2.5 mg one tablet by mouth two times a day/Hold if systolic Blood Pressure is over 120. Record review of resident #32's MAR for the month of May 2025 for Midodrine HCL 2.5 mg documented the medication was administered for the evening hour on 05/01/25 - BP [blood pressure] 128/80, early hour on 5/03/25 BP - 138/76, evening hour 05/09/25 - BP 144/86, early hour 5/11/25 BP - 130/76, evening on 05/14/25 - BP 131/77, evening hour 5/19/25 - BP 156/88, blank entry for the early hour on 5/24/25, early hour 5/25/25 - BP 145/77, evening 5/26/25 - BP 125/74. During a telephone interview on 05/29/25 at 02:15 PM Staff O, LPN stated, I did not give the medication the last time, I do not recall giving the medication on May 3, 2025. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105571 If continuation sheet Page 15 of 20 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 05/30/2025 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 - Some During a phone interview on 05/30/25 at 09:57 AM with Staff P, LPN regarding Midodrine HCL oral tablet 2.5 mg. Staff P stated, If I signed the medication as given it was signed in error, I always take her blood pressure and I know the parameters. During an interview on 05/30/25 at 12:25 PM Medical Doctor #2 stated, If medication was given out of parameter, it would not have a negative effect on the patient due to this drug is short active. I do think I will change the parameter from 120, to hold over 140. During a telephone interview on 05/30/25 at 12:46 PM Staff Q who stated, I did sign the medication out and there should be no blanks on the medication MAR. I know there are parameters and depending on what it was I either gave it or not I just can't remember what the blood pressure was. 6) Review of Resident #99's physician order dated 3/18/2025 read Aripiprazole Oral Tablet 5 mg give 10 mg by mouth at bedtime for schizophrenia. Review of Resident #99's physician order dated 2/23/2024 read Divalproex Sodium Tablet Delayed Release 250 mg give 1 tablet by mouth two times a day for Bipolar. Review of Resident #99's physician order dated 7/22/2024 read Sertraline HCl Tablet 100 mg give 1 tablet by mouth in the morning for major depressive disorder. Review of Resident #99's physician order dated 10/18/2022 read monitor and document behavior concerns using codes provided. Behavior code: 0-no behavior, 1-fear/panic, 2-anger, 3-scream/yell, 4-danger/self/others, 5-delusions, 6-hallucinations, 7-sad/tearful, 8-emotion/act withdrawal, 9-other (describe). Interventions: 1-redirect, 2-1 on 1, 3-Ambulate, 4-Activity, 5-Return to room, 6-Toilet, 7-Give food, 8-Give fluids, 9-Change position, 10-Encourage to rest, 11-Back rub, 12-PRN med. Outcome: I-Improved, S-Same, W-Worse. Side Effects: 0-None, 1-EPS [Extrapyramidal Symptoms], 2-Tardive Dyskinesia, 3-Hypotension, 4-Inc. Review of Resident #99's Treatment Administration Record for March 2025 for behavior monitoring showed staff documented code NA (Not Applicable) on 3/7/2025, 3/9/2025, 3/21/2025, and 3/24/2025 during the 7-3 shift; on 3/5/2027 and 3/22/2025 on the 3-11 shift; on 3/21/2025 during the 11-7 shift. Review of Resident #99's Treatment Administration Record for April 2025 for behavior monitoring showed staff documented code NA on 4/7/2025, 4/8/2025, 4/10/2025, 4/14/2025 and 4/15/2025 during the 7-3 shift; on 4/7/2025, 4/9/2025, 4/14/2025, and 4/23/2025 during the 3-11 shift. Review of Resident #99's Treatment Administration Record for May 2025 for behavior monitoring showed staff documented code NA on 5/8/2025, 5/16/2025, 5/22/2025 and 5/24/2025 on the 7-3 shift. During an interview on 5/30/2025 at 10:00 AM Staff S, LPN stated, You should document 0 if there are no behaviors. N/A is not appropriate. Review of Resident #111's physician order dated 1/17/2025 read Monitor and document behavior concerns using codes provided Behavior code:0 no behavior, 1 Fear/panic, 2 Anger, 3 Scream/yell, 4 Danger/self/others, 5 Delusions, 6 Hallucinations, 7 Sad/tearful, 8 Emotion/Act Withdrawal, 9 other(describe) Interventions:,1 Redirect, 2- 1 on 1, 3 Ambulate, 4 Activity, 5 Return to room, 6 Toilet, 7 Give food, 8 Give fluids, 9 Change position, 10 Encourage to rest ,11 Back rub, 12-PRN med. Outcome: I-Improved, S-Same, W-Worse. Side Effects: 0-None, 1-EPS, 2-Tardive Dys, 3-Hypotension, 4-Inc. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105571 If continuation sheet Page 16 of 20 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 05/30/2025 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 - Some Review of Resident #111's physician order dated 1/18/2025 read Amitriptyline HCl oral tablet 25 MG. Give 25 mg by mouth at bedtime for depression. Review of Resident #111's MAR for 04/01/2025 through 04/30/2025 documented NA for the Day Hours on 04/7/2025, 04/08/2025, 04/10/2025, 04/14/2025, 04/15/2025, and 04/17/2025. The Evening Hours on 04/07/2025, 04/08/2025, 04/14/2025, 04/23/2025, and 04/30/2025. Review of Resident #111's MAR for 05/01/2025 through 05/31/2025 documented NA for the Day Hours on 05/08/2025, 05/16/2025, 05/22/2025, and 05/25/2025. During an interview on 5/30/2025 at 2:00 PM, Staff S, LPN stated, If they don't have any behaviors, you document 0 for no occurrences. You should never document NA. During an interview on 5/30/2025 at 12:00 PM, the DON stated, They should always document according to the legend. NA is not on the legend for that section 7) During an observation on 5/27/25 at 2:11 PM, Resident #103 had a dual lumen, central venous catheter on his right upper chest with a dressing dated 5/1/25. (Photographic evidence obtained) During an interview on 5/27/25 at 2:11 PM, Resident #103 stated, The last time he was in the hospital they put in the catheter for antibiotics. Since my return to the facility, a nurse had said that the dressing needed to be changed, but that the dressing had not been changed. Review of Resident #103's Census Data documented the resident was initially admitted on [DATE] and most recently readmitted on [DATE]. Review of Resident #103's medical diagnoses included the following relevant information: pneumonia, unspecified organism; methicillin resistant staphylococcus aureus infection as the cause of diseases classified elsewhere; dependence on renal dialysis During an interview on 5/29/25 at 9:39 AM, the Medical Director stated, I do not recall being contacted on or around 5/1/25 regarding [Resident #103's name] orders upon readmission from the hospital. I was aware that the resident had a central vascular catheter and IV [intravenous] antibiotics, but I don't recall the nurse discussing any orders for the IV catheter. During an interview on 5/28/25 at 3:17 PM, Staff A, LPN stated, I have flushed [Resident #103's name] central venous catheter, as it was ordered to be done daily. I was not sure whether [Resident #103's name] had an order for a dressing change for his central venous catheter, and an order did not pop up in the computer to complete [a dressing change]. I didn't have time to investigate [for an order]. The admitting nurse should have identified whether there was an IV catheter and that it needed an order for a dressing change. During an interview on 5/29/25 at 9:55 AM the DON stated, When a resident is admitted the nurse completes an admission packet. The nurse would enter the medications and call the doctor to confirm the orders. A head-to-toe assessment would be expected to be done, which includes documentation of a skin check and documentation of any IVs, tubes, or drains. The nurse is expected to review the discharge summary from the hospital and would look to see if a specific type of IV line is mentioned. Review of Resident #103's Evaluation revealed a Clinical admission form dated 5/1/25. In the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105571 If continuation sheet Page 17 of 20 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 05/30/2025 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 - Some FORM CMS-2567 (02/99) Previous Versions Obsolete section for IV catheters/access, there was no documentation of a central venous catheter. The section for antibiotics did not contain documentation. Review of the policy and procedures titled, Charting and Documentation, with an effective date of October 2024, and last reviewed 1/31/25, read, Purpose: F 842 - The purpose of this procedure is to provide a complete, accurate, readily accessible and systematically organized medical record. The medical record will reflect a resident's progress toward achieving their person-centered plan of care objectives, goals and improvement and/or maintenance of their clinical, functional, mental and psychosocial status . Overview: . Clinical admission evaluation is initiated upon admission and completed within 24 hours . Event ID: Facility ID: 105571 If continuation sheet Page 18 of 20 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 05/30/2025 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 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 maintain appropriate infection prevention and control practices during medication administration for 2 of 15 residents, Residents #78 and #338) reviewed for medication administration practices, and failed to ensure appropriate infection control barriers were applied for residents with orders for isolation for 1 of 2 residents, Resident #129, reviewed for infection control. Residents Affected - Few Findings include: 1) During an observation on 5/29/25 at 11:09 AM, Staff D, Licensed Practical Nurse (LPN), donned gloves, and cleaned Resident #78's glucometer. After cleaning the glucometer, and removing her gloves, she dropped the gloves on the ground, picked them up and disposed of them. Staff D then donned a new pair of gloves, without performing hand hygiene, and removed Resident #78's insulin pen [a device used to administer insulin injections] from the medication cart and then removed and disposed of her gloves. Staff D donned a new pair of gloves without performing hand hygiene and entered Resident #78's room and performed a finger stick [a medical procedure where a small amount of blood is collected from the fingertip, typically by pricking the skin with a sterile lancet]; Staff D removed and disposed of her gloves before exiting Resident #78's room. Staff D donned a new pair of gloves without performing hand hygiene and administered the dosage of insulin ordered to Resident #78, via subcutaneous injection. During an interview on 5/29/25 at approximately 11:15 AM, Staff D, LPN stated, I had performed hand hygiene before I started cleaning the glucometer; I should have performed hand hygiene each time I changed my gloves. 2) During an observation on 5/29/25 at approximately 4:20 PM, Staff E, LPN donned gloves as the only form of personal protective equipment (PPE) and administered 10 milliliters of Sodium Chloride Solution 0.9% (normal saline) as ordered to flush Resident #338's PICC (peripherally inserted central catheter which is a long, thin catheter inserted into a vein in the arm and threaded up to a large vein in the chest, near the heart) line. During an interview on 5/29/25 at approximately 4:25 PM, Staff E, LPN stated, Residents [Resident #338] are on EBP [Enhanced Barrier Precautions] for reasons such as intravenous catheters (IVs). Depending on the reason for the EBP the staff are to wear gloves, gowns, and masks, and that those items would be put on in the resident's room, before care, and removed in the resident's room after care. Review of the policy and procedure titled, Enhanced Barrier Precautions, implemented on 8/16/22, and last reviewed 1/31/25, read, Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Definitions: Enhanced barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities for . those at increased risk for MDRO acquisition (e.g., residents with wounds or indwelling medical devices). Policy Explanation and Compliance Guideline: . 4. High-contact resident care activities include: . g. Device care or use: central lines . 7. Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until the wound heals or indwelling medical device is removed. Review of the policy and procedure titled, Infection Prevention and Control Program, with an effective date of 12/2020, and last reviewed 1/31/25, read, Mission of Program: The primary mission is to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105571 If continuation sheet Page 19 of 20 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 05/30/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few establish and maintain an Infection Prevention and Control Program (IPCP) designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infection. Policy: It is the policy that this facility's Infection Prevention and Control Program (IPCP), is based upon information from the facility assessment including the infection control risk assessment and follows the national standards and guidelines to prevent, recognize and control the onset and spread of infection whenever possible. The infection prevention and control program includes: 1. A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to regulatory requirements and following accepted national standards. 2. Written standards, policies, and the procedures for the program, which include: . f. The hand hygiene procedures . Review of the policy and procedure titled, 6.0 General Dose Preparation and Medication Administration, with an effective date of 12/1/07, and last reviewed on 1/31/25, read Applicability - This Policy 6.0 sets forth the procedures relating to general dose preparation and medication administration. Facility staff should also refer to facility policy regarding medication administration and should comply with applicable law and the state operations manual (SOM) when administering medications. Procedure 1. Prior to administering medications, authorized and competent facility staff should follow facility's infection control policy. 1.1 Appropriate hand hygiene should be performed before and after direct resident contact. 3) During an observation on 5/27/2025 at 10:10 AM, Resident #129 had an Enhanced Barrier Precaution sign posted on the door. The back of the sign noted gowns and gloves are required when entering the resident's room. During an interview on 5/27/2025 at 10:16 AM Staff W stated, [Resident #129's name] is supposed to be on contact precautions not enhanced barrier precautions. Review of Resident #129 physician orders dated 5/16/2025 read, Contact precautions every shift for pseudomonas to LLE [left lower extremity] surgical wound. Review of the policy and procedure titled, Transmission Based Precautions, reviewed on 1/31/2025 read, Standard Precautions shall be used when caring for residents at all times regardless of their suspected or confirmed infection status. Transmission based precautions shall be used when caring for residents who are documented or suspected to have communicable diseases or infections that can be transmitted to others. See Nurse Sign: posting will be on resident rooms alerting HCW's (healthcare workers), residents and visitors that they must see the nurse before entering room. The reverse side of the sign will note the type of precaution, method of acceptable hand disinfection and PPE to be utilized. The nurse will provide resident's specific precaution instructions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105571 If continuation sheet Page 20 of 20