Health inspection·December 10, 2021

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observations, interviews, and record review, the facility failed to develop comprehensive care plans related to the monitoring and placement of an elopement bracelet alarm on one (Resident # 424) of five residents sampled for accidents. Findings included: An observation on 12/07/21 at 3:15 p.m. revealed Resident #424 sitting in a wheelchair across from the nursing station with an elopement alarm bracelet located on the resident's right ankle. A review of Resident #424's admission record revealed medical diagnoses of weakness, focal traumatic brain injury, atrial fibrillation, vascular dementia, hearing loss, and adjustment disorder with mixed anxiety. Resident #424's care plan revealed focus areas related to being a fall risk with poor safety awareness with unsafe ambulation (date initiated 12/01/21), and impaired cognition with short-term and long-term memory deficits with problems understanding others due to disease process and vascular dementia (date initiated 12/02/21). The care plan did not identify interventions related to monitoring placement and functionality of an elopement alarm bracelet. Additional review of the record revealed no documentation related to monitoring or placement of an elopement alarm bracelet. Continued review showed an Elopement Risk Scale assessment completed on 12/03/21 which revealed a score of 13; indicating the resident was at High Risk to Wander. Page 2 of this assessment revealed an elopement risk intervention was to Apply monitoring device bracelet. In an interview on 12/09/21 at 9:37 a.m. Staff K, Licensed Practical Nurse (LPN) stated the nursing staff are responsible for checking the placement and functionality of a resident's elopement bracelet alarm. Staff K, LPN reviewed Resident #424's online medical record and confirmed there were no active physician orders or care plan interventions for the placement or functionality checking of the resident's elopement alarm bracelet. Staff K, LPN stated the resident's assigned nurse should be checking the placement of the elopement alarm bracelet daily and the restorative certified nursing assistants check the functionality of the bracelet weekly. In an interview on 12/09/21 at 9:55 a.m. Staff I, Assistant Director of Clinical Services (ADCS)/Unit Manager stated Resident #424 displayed signs of exit seeking behaviors. After an evaluation, an elopement alarm bracelet was placed on the resident. The Unit Manager confirmed a physician order and care plan interventions should have been put into place for monitoring of the elopement alarm bracelet. An interview on 12/09/21 at 3:04 p.m. with the Director of Clinical Services (DCS) confirmed the expectation is for a physician order to be in place for the placement, tracking, and monitoring of an elopement alarm bracelet. The DCS confirmed the expectation that the plan of care for a resident is accurate and followed. A document review, used by the facility to guide the creation of a complete and comprehensive plan of care entitled CH [chapter] 4: . Care Planning, dated October 2019, revealed on page 4, that . the comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105574 If continuation sheet Page 2 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105574 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Largo 10500 Starkey Rd Largo, FL 33777 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 Residents Affected - Few must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care . all resident assessments completed within the previous 15 months in the resident's active record and use the results of the assessments to development, review, and revise the resident's comprehensive plan of care . A policy review of Elopement Risk, revised in March 2018, revealed It is the policy of this center that an elopement risk evaluation is completed upon admission. All residents will be evaluated for elopement risk following admission, quarterly, and with a change in condition or significant event. PROCEDURE 1. If the resident is identified as an elopement risk based on the evaluation, a care plan will be developed to reduce elopement risk . A policy review of Physician's Orders, effective date of October 2014, revealed All resident medications must be ordered by a licensed physician, ARNP [advanced registered nurse practitioner], or PA [physician assistant] . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105574 If continuation sheet Page 3 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105574 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Largo 10500 Starkey Rd Largo, FL 33777 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** 3. Resident observed on 12/8/2021 at 12:18 p.m. with linear and circular markings along the left shoulder and Right lower leg. Resident #64 was observed scratching at her shoulder. Residents Affected - Some Review of weekly skin checks dated 12/9/2021 revealed the resident had impaired skin. Review of the Situation, Background, Appearance, Review and notify (SBAR) form dated 12/9/21 detailed the resident with skin or wound ulcer. Primary care clinician notified on 12/9/21 at 11:40 a.m. and ordered lac hydrin lotion for dry skin. Review of the weekly skin assessment dated [DATE] at 5:13 p.m. revealed the resident with intact skin. Review of the weekly skin assessment dated [DATE] at 5:13 p.m. revealed the resident with intact skin. Review of the weekly skin assessment dated [DATE] at 8:13 p.m. revealed the resident with intact skin. Review of the weekly skin assessment dated [DATE] at 8:13 p.m. revealed the resident with intact skin. Review of the care plan revealed the resident focus area of risk for alteration in skin integrity related to fragile skin initiated on 7/16/19 and revised on 10/7/21. Interventions included skin check as per facility protocol initiated on 7/16/19, Observe for signs and symptoms of alteration in skin and report initiated on 7/16/19. Review of physician orders included Lac-Hydrin lotion 12% - apply to arms, legs, chest topically every day and night for dry skin. Ordered on 12/9/21 to start on 12/10/21. During an interview with the Director of Nursing on 12/10/21 at 3:30 p.m. he confirmed skin assessments are to be completed every 7 days and confirmed the skin assessments for Resident #64 were not competed timely. Based on observation, interview, and record review, the facility failed to ensure care and services were provided to four (#24, 33, 43 and 64) of thirty-six sampled residents as evidenced by: 1) inaccurate skin assessment for #24; 2) not providing care and services in timely manner for a change in skin integrity for #33 and #43; and 3) and not performing weekly skin assessments for #64. Findings Included: 1. On 12/07/21 at 10:10 a.m. an interview was conducted with Staff C, Registered Nurse Unit Manager outside Resident #24's room. Signs on the door indicated 'contact precautions.' Staff C stated, her daughter took her out to a dermatologist. They returned to the facility stating her mother had scabies. Staff C said she called the dermatologist's office and they had denied she had scabies. She said the resident is being treated with a cream and has seen improvement in her itching. Resident #24 was observed from the doorway at that time. The resident smiled and stated, it itches. As she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105574 If continuation sheet Page 4 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105574 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Largo 10500 Starkey Rd Largo, FL 33777 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 - Some immediately started to rub her left upper extremity, her arm was observed with small scratches and scattered scabs presenting over 50 % of the left upper extremity (LUE). On the bedside table a box was noted that contained a pharmacy label. Staff Member B, Certified Nursing Assistant (CNA) was asked about the box, and brought it to the door stating, I had applied the cream to her on Friday. [Staff member L, Licensed Practical Nurse (LPN] gave it to me and told me to apply it to the resident. Photographic evidence was obtained. A record review revealed an admission Record form showing the resident had resided at the facility for over two years. Diagnosis information did not include a history of skin disorders. Review of the Weekly Skin Check assessment dated on 12/2/2021 revealed the resident's skin was intact. On 12/08/2021 at 3:40 p.m. the Director of Nursing (DON) provided a copy of the Dermatology report dated on 12/2/2021. It showed: Chief Complaint: Skin Lesions Being seen for a chief compliant of skin lesions, located on the left forearm and right forearm. the lesions are itchy, new, red, and tender and moderate in severity. The lesions have been present for months. Nothing makes the lesions better or worse. These lesions have not been treated in the past. Impression/Plan erythematous eczematous patches located on the middle sternum, Dx [diagnosis] includes: scabies vs [versus]. less likely drug eruption. Plan: Prescription: Ivermectin 3 milligrams (mg) take 4 pills now, repeat in 2 weeks and permethrin 5% topical cream apply neck down to feet at night on day 0 then wash off in morning, repeat on day 7. On 12/10/2021 at 3:29 p.m. a phone interview was conducted with Staff L, LPN. She confirmed she had performed the Weekly Skin Check on 12/02/2021 and said she had documented the resident's skin was intact. Staff L then stated, she only had a little rash around her knee. Further record review of the resident's Primary Physician notes dated on 12/03/2021 showed: Narrative: c/o [complaining of] persistent itching, saw dermatologist and empirically ordered permathine cream (crm.) and ivermectin. 8a. Other SKIN findings: itchy rash. Narrative- Atypical dermatitis, unlikely to be scabies. 2. On 12/07/21 at 10:15 a.m. Resident #33 was observed lying in bed. The right wrist of the resident's sweatshirt, along with the forearm and upper area of the sleeve contained dried dark ruby red colored spots. Resident #33 pushed up the right sleeve of his shirt and revealed multiple scratches from his upper deltoid down to the wrist. The scratches presented as new, old, and in healing stages with intact scabs. The surrounding skin contained dried bloody residual and patches of dried flaky areas. His left arm did not have any scratches. Staff Member C, Registered Nurse (RN) and the Unit Manager was present and confirmed the spots of ruby red drainage on his sweatshirt. Resident #33 said his skin started to itch about a month ago and denied telling anyone about the itching. On 12/08/2021 at 11:32 a.m. Resident # 33 was observed lying in bed and wearing the same sweatshirt with the dried dark reddish-brown spots. He pushed the sleeves upward revealing his left forearm that contained scratches not present during the prior day's observation. He then stated, you should see my legs. At that time, he pulled up his left pant leg. His leg revealed from the knee to the top of his foot with new and old scratches with intact scabs and dry flaky skin. He stated, it itches like crazy and began rubbing his right upper arm. The resident stated, staff know about it. A record review revealed an admission Record form showing the resident had resident had resided at the facility for three years, and diagnoses that included erythematous conditions and actinic keratosis. A visit report from the facility's external Wound Advanced Practice Registered Nurse (APRN) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105574 If continuation sheet Page 5 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105574 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Largo 10500 Starkey Rd Largo, FL 33777 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 - Some dated on 10/08/2021 showed: Chief Complaint the patient was seen today for up and management of the patient's skin. Location: allergic urticaria located trunk and bilateral upper extremity (BUE) continues to improve slowly. Duration: has been greater than 3 weeks. Associated Signs and Symptoms: there is no pain, c/o pruritis, and markedly less areas of erythematous papules and scale. Psychiatric: the patient appears to have good judgement and insight. The patient is oriented to person, time, and place. There is normal affect. And no signs of anxiety or agitation. A review of Physician Orders revealed an order for ammonium lactate 12% cream apply to both arms and legs topically every day and evening shift for dry skin, dated 3/11/2021. The treatment administration record review for November and December 2021 reflected documentation it had been administered two times a day as ordered. On 12/09/2021 at 10:00 a.m. Staff C provided the physician ordered cream for Resident #33. The tube contained over 25 % of the cream. The pharmacy label revealed the last time it had been delivered to the facility was on 07/17/2021 (photographic evidence obtained). At 10:35 p.m. on 12/09/2021 an observation was conducted with the facility Wound Nurse. The Wound Nurse stated, his skin is extremely dry and said she would have the nurse practitioner see him. Staff B, CNA was present and confirmed at that time she had told the Staff C and the night nurse about his skin. She then pointed to the sink and stated, I use that cream on him. She confirmed she was using a bottle of house lotion on the resident's skin. On 12/10/2021 at 3:00 p.m. an interview was conducted by phone with the facility's pharmacy. The Lead Technician confirmed the last time the cream for Resident #33 was ordered was on 07/17/2021. The Lead Technician confirmed it was her expectation the cream would have been re-ordered sooner. She stated yes, it should have been replaced before now. On 12/07/21 at 12:33 p.m. Resident #43 was observed and a dressing was noted to his left forearm just proximal to his elbow that did not contain a date. The dressing contained shadow drainage that was dark red, to pink in color. Staff C was present and confirmed the presence of the stained dressing. Medical record review of the admission Record form revealed Resident #43 was receiving hospice services. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominate side. No orders were in place for care and treatment of the open area on his forearm. On 12/8/2021 at 10:25 a.m. Resident #43 was observed lying in bed. Staff C was present in the room and assisted the resident with repositioning his left arm. The left forearm was noted no longer containing a dressing and revealing an open area the size of a 50-cent piece. The wound was bright red in color and the edges contained dried brown to red colored drainage. Staff C stated, I thought that [Staff M, Registered Nurse (RN)] knew about it. At 10:40 on 12/08/2021 an interview was conducted with Staff M who confirmed she had seen Resident #43's arm in the morning of 12/7/2021. She said she called and notified the Physician on 12/7/2021. Staff M confirmed she did not document she had contacted the Physician and also confirmed there were no current orders in place for wound care. Review of the facility policy on Skin Care & Wound Management revision date on July 2017. Policy as part of an ongoing Quality Assurance process, skin care and wound management guidelines are to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105574 If continuation sheet Page 6 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105574 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Largo 10500 Starkey Rd Largo, FL 33777 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 - Some FORM CMS-2567 (02/99) Previous Versions Obsolete provide necessary treatment and services to promote healing, prevent infection, control pain, and prevent development of pressure injury (s) unless the residents clinical condition demonstrates that they are rare unavoidable. Inspection and wound management. The skin Grid-other with be completed upon identification of impairment skin tear, laceration, abrasion, rash, or any other significant skin condition is found. In addition, the CNA will document results of daily skin inspections per center protocol and report any changes or area of concern to the nurse and or physician. Current standards of practice will be used for skin and wound management. Physician treatment orders obtained and documented on the TAR (Treatment Administration Record). Resident/resident representative /family will be notified of the skin impairment and treatment plan. The resident plan of care will be reviewed and revised as needed. New interventions will be communicated the care giving team. Event ID: Facility ID: 105574 If continuation sheet Page 7 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105574 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Largo 10500 Starkey Rd Largo, FL 33777 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 prescribed biological medications were secured for one Resident #29 on three (12/08/21, 12/09/21 and 12/10/21) of four days observed. Findings Included: During an interview and observation with Resident #29 on 12/8/21 at 12:48 p.m. three tubes of medication were observed in a clear plastic bag in the resident's room. The medications were Clotrimazole-Betamethasone Cream, Ammonium Lactate Cream 12%, and triple antibiotic ointment, and were labelled with the resident's last name. Photographic evidence was obtained. On 12/09/21 at 10:32 a.m. Resident #29 was observed sitting in a recliner talking with the nurse. The bag containing the three biological medications was observed on the resident's bedside table. An observation on 12/10/21 at 8:00 a.m. with the Director of Nursing (DON), confirmed the three medicated creams were in a clear plastic bag labelled with the resident's name and located in the resident's room. The DON stated the medications should be secured in the medication cart by the nurse. The DON confirmed the medicated ointments should be administered by the nurse and not left the room. Review of physician orders revealed: -Clotrimazole-Betamethasone cream 1-0.05% Apply to both feet and toes topically every day shift for fungal infection apply generous amount to both feet and in between toes dated 11/1/21. -Lac-Hydrin Cream 12% (ammonium lactate) apply to bilateral leg and foot topically every day and evening shift for dry skin dated 10/13/21. Review of facility policy for Medications, Storage of effective December 2020, page one, revealed: The purpose of this procedure is to ensure the medications are stored in a safe, secure, and orderly manner. 1. Medications are stored in the containers in which they are received. Transfer between containers is performed only by the issuing pharmacy. 7. Medications are stored in an orderly manner in cabinets, drawers, or carts. These compartments are of sufficient size to prevent crowding. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105574 If continuation sheet Page 8 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105574 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Largo 10500 Starkey Rd Largo, FL 33777 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and the facility Plan of Correction review, the facility failed to ensure it had a functioning Quality Assurance Committee. The facility had deficient practices identified during the Recertification and Complaint survey for complaint numbers 2021003271, 2020019788, and 2020011362, conducted on [DATE] to [DATE] and was cited F684. The facility developed a Plan of Correction with a completion date of [DATE]. On [DATE], the facility was recited F684 for failure to ensure Best Practice for Peripherally Inserted Central Catheters (PICC) was utilized for three (#5, #9, #10) out of three sampled residents on intravenous therapy, as evidenced by omitted monitoring, medication, intermediate flushes, and dressing changes. The facility had not comprehensively implemented the plan of correction for the identified deficiency. Findings included: A review of the facility Quality Assurance and Performance Improvement (QAPI) plan, policy, and procedures, undated, documented: Palm Garden of Largo's performance improvement system is centered around the Quality Assurance and Performance Improvement (QAPI) process. The QAPI committee is comprised of Palm Garden of Largo's Senior Leaders (SL), key partners and suppliers, consulting physicians, and representatives from the front-line members. The QAPI committee meets at a minimum monthly and reports metrics related to key processes to include clinical care, quality of life, resident choices, regulatory compliance, infection control, adverse incidents, safety, and customer satisfaction. The QAPI committee analyses reported data, determines opportunities for improvement (OFI) and initiates Performance Improvement Projects (PIP) as needed. When a PIP is initiated, a PIP committee is formed and tasked to develop a 4-step plan to address the OFI. The PIP must utilize Plan Do Check Act (PDCA) when implementing their plan. Each PIP must answer the following questions: 1. How will the OFI be corrected for the identified individuals? 2. How will the PIP Committee ensure no other individuals were affected? 3. What systemic changes will be put in place to correct the OFI going forward? 4. How will the PIP Committee monitor Quantifiable data to ensure the interventions were effective? In addition to the OFIs, the QAPI Committee reviews Palm Garden of Largo's strategic plan for compliance each month. This process allows for the strategic plan to be reviewed and revised as needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105574 If continuation sheet Page 9 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105574 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Largo 10500 Starkey Rd Largo, FL 33777 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 0867 Meeting minutes from QAPI are shared with team members each month. Level of Harm - Minimal harm or potential for actual harm A review of the facility Quality Assurance Performance Improvement (QAPI) sign in sheets, reflected the facility held an Ad HOC meeting on [DATE] to review the deficiencies cited during the recertification survey, conducted on [DATE] through [DATE], and the Plan of Correction for the deficiencies cited. In addition, the facility provided a sign in sheet for a QAPI meeting that was conducted on [DATE]. Residents Affected - Some A review of the facility's Plan of Correction for F684, with the completion date of [DATE], included: -The director of Clinical Services and/or designee audited residents to ensure weekly skin checks were completed accurately and skin care was provided in a timely manner. -The Director of Education and/or designee will re-educate licensed nursing staff regarding accurate weekly skin assessments, application of prescribed medications and timeliness of skin care and wound management. The Director of Education and/or designee will conduct audits of residents' skin checks and treatments 5 days a week for 2 weeks. Thereafter audits will continue 2 times a week for 4 weeks and then 1 time a week for 4 weeks. The results will be reported to the QAPI committee monthly for 3 months. The QAPI committee will re-evaluate the need for future monitoring after 3 months. -The Executive Director met with the Medical Director to review the alleged deficient practices. The QAPI committee will review the effectiveness of the interventions as outcomes as studied to achieve substantial compliance. The QAPI committee will continue to review education, processes, systems, and audits for a minimum of 3 months post substantial compliance to assure the systems remain effective. On [DATE] at 5:15 p.m., an interview was conducted with the Quality Assurance Nurse (QAN), the Director of Nursing (DON), and the Nursing Home Administrator (NHA). The DON reported the plan of correction focused on skin assessment, skin impairment, and skin change. The DON reported a house wide audit was conducted to see if there were any other skin areas and skin checks were updated that were not accurate and these were added to the skin grid. He reported the wound nurse would have them added to their schedule. He stated upon the admission, the nurse would assess the resident and document in the skin tab. The next day, the wound nurse would go to validate what was there or not there. And if needed, the ARNP (Advanced Registered Nurse Practitioner) comes in on Friday. For the assessment, the nurse, RN (Registered Nurse) was doing the head to toe. For the wound nurse, doing another head to toe; she is more clinical. On [DATE], it was determined, based on observation, interviews, medical record, and the facility policy the facility failed to ensure that Best Practice for Peripherally Inserted Central Catheters was utilized for three (#5, #9, #10) out of three sampled residents on intravenous therapy as evidenced by omitted monitoring, medication, intermediate flushes, and dressing changes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105574 If continuation sheet Page 10 of 10