Health inspection·February 10, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow the comprehensive person-centered care plan for three (#2, #4, #5) of three sampled residents related to bed mobility and transfers. Findings included: 1. Resident #2 was admitted on [DATE] and readmitted on [DATE]. Review of the admission Record showed diagnoses included but not limited to traumatic subarachnoid hemorrhage without loss of consciousness on 08/18/2021; orthostatic hypotension, intervertebral disc displacement, lumbar region; other specified disorders of the brain; diabetes; anemia; adult failure to thrive; unspecified dementia severe; Cognitive Communication Deficit; stage 3 chronic kidney disease; Chronic Obstructive Pulmonary Disease, tremor, low back pain, hypertensive chronic kidney disease and spondylosis. Review of the Care Plans showed: ADL (Activities of Daily Living) Self-Care and/or mobility deficit. Resident #2 was at risk of developing complications associated with decreased ADL self-performance related to: weakness, tremors, often chooses to not get out of bed as of 08/19/2021 and revised 02/03/2025. Interventions included but not limited to: Bed Mobility are total assist of 2 related to air mattress; Transfers are total assist of 2 with the mechanical lift; Bathing was total assist of 2; Toileting was total assist of 2 as of 10/05/2023. Review of the ADL Tasks dated 01/12/2025 to 01/31/2025 Bed Mobility-how resident moves to and from a lying position, turns side to side, and positions body while in bed: Bed Mobility required total dependence assistance for 34 out of 44 opportunities Bed Mobility required extensive assistance for 6 out of 44 opportunities Bed Mobility required limited assistance for 2 out of 44 opportunities Bed Mobility required resident not available for 1 out of 44 opportunities Bed Mobility is not applicable for 1 out of 44 opportunities Page 1 of 5 105574 105574 02/10/2025 Palm Garden of Largo 10500 Starkey Rd Largo, FL 33777

F 0656 Bed Mobility- how resident moves to and from a lying position, turns side to side, and positions body while in bed: Level of Harm - Minimal harm or potential for actual harm Bed Mobility required two + persons physical assistance for 5 out of 43 opportunities Residents Affected - Some Bed Mobility required one-person physical assistance for 37 out of 43 opportunities Bed Mobility required resident not available for 1 out of 43 opportunities During an interview on 02/10/2025 at 12:06 p.m., the Director of Nursing (DON) and Risk Manager (RM) revealed the following information. On 01/13/2025 at approximately 8:00 a.m., Staff A, Certified Nursing Assistant (CNA) was trying to turn Resident #2 on his left side. He was facing away from her. While she was changing his brief, he rolled off the mattress. The RM started the investigation on 01/13/2025 and spoke with Staff A, CNA, regarding details. The RM reviewed the resident's care plan and noted the resident was a two person assist for bed mobility. The RM gave one on one education to Staff A, CNA. The DON and the RM stated they performed an audit of all the care plans of residents on air mattresses to ensure their care plans showed two persons assist. They stated they were all in compliance. 2. Resident #4 was admitted on [DATE]. Review of the admission Record showed diagnoses included but not limited to spinal stenosis of the cervical region, asthma, a history of traumatic brain injury, weakness, and history of falls. Review of the Care Plans showed: Resident #4 had ADL self-care and /or mobility deficit. Needed assistance with ADLs, at risk of developing complications associated with decreased ADL self-performance related to disease process/condition, weakness, asthma, migraines, morbid obesity as of 09/10/2024 and revised 01/10/2025. Interventions included but not limited to: Bed Mobility are total assistance of 2 related to air mattress; Transfers are total assist of 2 with the mechanical lift; Bathing was total assist of 2; Toileting was total assist of 2 as of 09/10/2024 and revised on 01/29/2025. Review of the ADL Tasks dated 01/12/2025 to 02/10/2025 Bed Mobility-how resident moves to and from a lying position, turns side to side, and positions body while in bed: Bed Mobility required total dependence assistance for 58 out of 86 opportunities Bed Mobility required extensive assistance for 24 out of 86 opportunities Bed Mobility required limited assistance for 3 out of 86 opportunities Bed Mobility required independent assistance for 1 out of 86 opportunities Bed Mobility- how resident moves to and from a lying position, turns side to side, and positions body while in bed: 105574 Page 2 of 5 105574 02/10/2025 Palm Garden of Largo 10500 Starkey Rd Largo, FL 33777

F 0656 Bed Mobility required two + persons physical assistance for 12 out of 86 opportunities Level of Harm - Minimal harm or potential for actual harm Bed Mobility required one-person physical assistance for 74 out of 86 opportunities Residents Affected - Some Transfers-How resident moves between surfaces including to or from bed, chair, wheelchair, standing position Transfers required total dependence for 21 of 30 opportunities Transfers required extensive assistance for 7 of 30 opportunities Transfers required limited assistance for 2 of 30 opportunities Transfers-How resident moves between surfaces including to or from bed, chair, wheelchair, standing position Transfers required two + persons physical assistance for 18 out of 30 opportunities Transfers required one-person physical assistance for 12 out of 30 opportunities During an interview on 02/10/2025 at 3:07 p.m., the DON verified Resident #4 was a 2-persons assist for bed mobility and transfers. The DON verified the documentation showed the staff was performing 1-person assists for bed mobility and transfers. The DON stated she would expect to see 2-persons assist for this resident. 3. Resident #5 was admitted on [DATE] and readmitted on [DATE]. Review of the admission Record showed diagnoses included but not limited to displaced intertrochanteric fracture of left femur, orthopedic aftercare; osteoarthritis (OA) of left hip, congestive heart failure (CHF), ischemic cardiomyopathy; dementia, history of falls, history of traumatic brain injury on 09/24/2024, delirium due to known psychological condition, hypotension. Review of the Care Plans showed: Resident #5 had ADL self-care and/or mobility deficit. Resident needed assistance with ADL's and was at risk of developing complications associated with decreased ADL self-performance related to left intertrochanteric femur fracture status post-surgery, weight bearing as tolerated left lower extremity, OA left hip, dementia, CHF, disease process/condition, weakness as of 06/01/2024 and revised on 11/21/2024. Interventions included but not limited to: Bed Mobility are limited assistance of 2; Transfers are limited assistance of 2; Toileting are limited assist of 2. Review of the ADL Tasks dated 01/12/2025 to 02/10/2025 Bed Mobility-how resident moves to and from a lying position, turns side to side, and positions body while in bed: Bed Mobility required total dependence assistance for 5 out of 83 opportunities Bed Mobility required extensive assistance for 25 out of 86 opportunities 105574 Page 3 of 5 105574 02/10/2025 Palm Garden of Largo 10500 Starkey Rd Largo, FL 33777

F 0656 Bed Mobility required limited assistance for 32 out of 83 opportunities Level of Harm - Minimal harm or potential for actual harm Bed Mobility required independent assistance for 21 out of 83 opportunities Residents Affected - Some Bed Mobility- how resident moves to and from a lying position, turns side to side, and positions body while in bed: Bed Mobility required two + persons physical assistance for 1 out of 83 opportunities Bed Mobility required one-person physical assistance for 61 out of 83 opportunities Bed Mobility required set up only for assistance for 2 out of 83 opportunities Bed Mobility required no set up or physical help from staff for 19 out of 83 opportunities Transfers-How resident moves between surfaces including to or from bed, chair, wheelchair, standing position Transfers required total dependence for 4 of 54 opportunities Transfers required extensive assistance for 7 of 54 opportunities Transfers required limited assistance for 27 of 54 opportunities Transfers required supervision for 16 of 54 opportunities Transfers-How resident moves between surfaces including to or from bed, chair, wheelchair, standing position Transfers required two + persons physical assistance for 0 out of 54 opportunities Transfers required one-person physical assistance for 38 out of 54 opportunities Transfers required set up only for 16 out of 54 opportunities During an interview on 02/10/2025 at 3:07 p.m., the DON verified Resident #5 was care planned for a 2-person limited assist for bed mobility and transfers. The DON verified the documentation showed the resident was only being assisted by one person for bed mobility and transfers. The DON stated she would expect to see the resident receive 2-person assistance. The DON stated she would have to have therapy to re-evaluate the resident. The DON stated she needed an evaluation to update the resident's transfer status. During an interview on 02/10/2025 at 3:58 p.m., the MDS RN (Minimum Data Set, Registered Nurse) stated a therapy evaluation was completed as well as a nursing assessment from which a baseline for the resident was formed. The assessment was performed quarterly or for a significant change. She stated the aides would let us know of a decline in the resident and we would have therapy re-evaluate. The aides were to follow the [NAME] / care plan and if it said 2-person assist, that was what they were supposed to do. The Interdisciplinary team met for morning meetings to discuss any changes. 105574 Page 4 of 5 105574 02/10/2025 Palm Garden of Largo 10500 Starkey Rd Largo, FL 33777

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the facility's policy, Person-Centered Comprehensive Care Plan, dated October 2022 showed it is the practice of the center to develop and implement a person-centered comprehensive care plan that include measurable objectives and time frames to meet their preferences and goals, and address the guest / resident's nursing, medical, physical, mental, and psychosocial needs. The conference care plan will be developed within 7 days after completion of the comprehensive assessment and no more than 21 days after admission. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each assessment, including both comprehensive and quarterly review assessments and with significant changes in the guest / resident's condition. The interdisciplinary team will work collaboratively with the guest/resident, responsible party and or family members to develop a comprehensive person-centered care plan that encompasses each guest/resident's personal preferences, goals, and objectives. The comprehensive person-centered care plan will address the following services: Services to be furnished to attain or maintain the guest/resident's highest practicable physical, mental, and psychosocial well-being. 105574 Page 5 of 5