Health inspection·December 15, 2022

F 0554 12/14/22 at 9:09 a.m., indicated the resident had removed the nebulizer mask. Level of Harm - Minimal harm or potential for actual harm On 12/14/22 beginning at 9:17 a.m., during an observation of Resident #86 and an interview with Staff I, Licensed Practical Nurse (LPN), Staff I stated, a nebulizer treatment had been given to Resident #86. Staff I reported nebulizer treatments could take about 10 - 15 minutes depending on the machine's compressor. Staff I reviewed Resident #86's physician orders and stated it did not look like the resident had an order to allow for the self-administration of the nebulizer medication. Staff I entered Resident #86's room, picked up the nebulizer mask from top of the bedside dresser, looked at it, then placed it into the plastic bag hanging from the bedside dresser under the nebulizer machine. When asked, the nurse removed the mask and indicated the nebulizer's medication cup still held a clear liquid. Staff I informed the resident the treatment would have to continue and placed the mask on the resident. The nurse stated, have to stay and watch [the treatment]. Staff I sat in the bedside chair next to Resident #86's bed. Staff I stated the procedure [for administration of nebulizer medication] was they (nurses) generally check back in on them [the residents]. Residents Affected - Few On 12/14/22 at 5:48 p.m., the Director of Nursing (DON) stated she knew about the incident with Resident #86. She said she was there, and heard what the nurse (Staff I) had told this writer. She stated her expectation would be that staff stay with the resident during the treatment. A review of Resident #86's admission Record revealed the resident was admitted on [DATE]. The record included a diagnosis not limited to unspecified chronic obstructive pulmonary disease. The 5-day Minimum Data Set (MDS) revealed a Brief Interview of Mental Status (BIMS) score of 10 out of 15, indicating a moderate cognition impairment. The review of Resident #86's Order Summary Report, active as of 12/14/22 at 9:47 a.m., did not include a physician order for the self-administration of any medication. The consent form for Self-Administration of Medication (undated) indicated It is the policy of this facility that the resident has the right to self-administer his or her own mediation if the interdisciplinary team has determined that the practice is safe. The form included but was not limited to the following criteria be met: 1. Physician's orders for administration of medication must be on file at the facility (may be all or a specific drug). 2. The resident has signed a document stating his/her desire to self-medicate. 3. The level of ability to identify medication, dosage, time, and to store properly has been determined as sage by the interdisciplinary team. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105581 If continuation sheet Page 2 of 19 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 105581 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Clearwater 3480 McMullen Booth Rd Clearwater, FL 33761 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record reviews, the facility failed to implement an effective grievance program for two (Residents #515 and #43) of 47 sampled residents related to the operation of in-room telephone service and missing property. Findings included: 1. On 12/13/22 at 10:42 a.m., the family member of Resident #515 stated the phone in the resident's room did not work and asked how families were supposed to communicate if they (the resident) did not have a cell phone. The family member expressed, on 12/13/22 at 11:50 a.m., the only issue was the phone was not working and said maintenance had been in over the weekend and changed it out but it still only got a busy signal. The observation identified a white telephone handset that when turned on, a busy signal could be heard. On 12/13/22 at 11:52 a.m., during an interview with Staff M, Agency Licensed Practical Nurse (LPN), she stated she was unaware of the telephone not working and if something did not work she would put it into the electronic maintenance system. On 12/13/22 at 12:06 p.m., during an interview with the Director of Plant Operations (DPO), he stated the phone not working in Resident #515's room was an ongoing issue. He stated they (the facility) was putting in a new system, business phones, going to be 4 phases, and as far as he knew phase one had been completed last week. The director stated to make a phone call, the resident could ask to use the cordless phone at the nursing station. On 12/15/22 at 2:39 p.m., the Nursing Home Administrator (NHA) stated phone numbers (to rooms) were posted in the rooms and the receptionist informed families of individual room numbers. She stated the Director of Customer Service should be notifying the family regarding (facility) phone numbers. She reported that room [ROOM NUMBER]'s phone was not going to work. On 12/15/22 at 2:46 p.m., the Director of Customer Service (DCS) stated, the Guest Relations department was responsible to let family and residents the phone in room [ROOM NUMBER] did not work. He stated a cordless phone was always available and the phone number was the facility's main phone number. The DCS identified the main phone number was on every business care and every room had a teepee card with the main phone number. He stated if there was a known issue I informed them and room [ROOM NUMBER]'s phone had been out. The clinical record for Resident #515 identified that the resident was admitted on [DATE]. A review of the grievance log, dated December 2022, did not identify a grievance had been filed regarding Resident #515's phone. 2. On 12/13/22 at 10:56 a.m., an interview was conducted with Resident #43. She reported a personal cell phone was missing and had disappeared either Friday or Saturday (12/10 or 12/11/2022). She said she reported the missing phone to an aide and was told laundry was looking for it. A review of the December 2022 did not indicate a grievance had been implemented regarding Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105581 If continuation sheet Page 3 of 19 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 105581 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Clearwater 3480 McMullen Booth Rd Clearwater, FL 33761 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 0585 #43's missing personal possessions. Level of Harm - Minimal harm or potential for actual harm The admission Record identified Resident #43 was admitted on [DATE] and included the following diagnoses of cellulitis of left lower limb and type 2 Diabetes mellitus. The 5-day Minimum Data Set indicated Resident #43 had a Brief Interview of Mental Status of 14 out of 15, which indicated intact cognition. Residents Affected - Few Resident #43's Inventory of Personal Effects list, dated 11/27/22, identified the resident had one cell phone and no valuables. On 12/14/22 at 5:22 p.m., interviews were conducted with Staff N and O, Social Service Directors, they revealed they were just made aware of Resident #43's missing phone. Staff O stated they would be making a grievance out regarding the phone. On 12/15/22 at 8:35 a.m., Staff O reported the cell phone had been located on the 200- unit, way over there and did not know how it had gotten there. The policy - Grievance Policy and Procedure, effective March 2015 and revised January 2018 and July 2021, identified that The center recognizes the resident/legal representative/family has the right to voice grievances and recommendations for changes through an orderly and timely process free from discrimination and/or reprisal. The have a right to expect the center will make prompt efforts to resolve grievances and, upon request, have the right to obtain written decision regarding the grievance. The procedure defined a concern as any formal expression of interest regarding the well-being of a resident. Upon receipt of the concern/grievance, documentation on the Record o Resident/Family Grievance/Complaint/Concern form will be initiated by the Grievance Official/designee or whichever professional team members receives the concern. The policy identified that the grievance official/designee would document the date the grievance was received on the Grievance log and copies would be made and distributed to the Executive Director and referenced department representative. The person filing the grievance has the right to expect the center will make prompt efforts to resolve grievances and, upon request, have the right to obtain written decision regarding the grievance. Residents who are unable to prepare a written grievance without assistance, may elect to receive support from any center team members or third party chosen by the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105581 If continuation sheet Page 4 of 19 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 105581 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Clearwater 3480 McMullen Booth Rd Clearwater, FL 33761 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility did not ensure fall interventions were implemented per care plan for one (Resident #144) of eight residents reviewed for falls. Residents Affected - Few Findings included: Resident #144 was admitted to the facility on [DATE] with diagnoses to include Encephalopathy unspecified Dementia, Parkinson's disease, anxiety disorder, muscle weakness, and history of falling. A care plan for Resident #144 dated 12/6/22, showed the resident was at risk for falls related to Parkinson's disease , Glaucoma, unsteady Gait, and history of falls. Interventions included: Calf pads in place when [Resident #144] is in wheelchair. Review of a document titled, SBAR (Situation, Background, Assessment and Recommendation) Communication form, dated 12/07/22, showed Resident #144 was found on the floor in the activity room on C-wing by housekeeping. Resident was lying in front of his wheelchair with his back against his foot pedals, seems as if he slid down out of his wheelchair and onto the floor . On 12/12/22 at 10:45 a.m., Resident #144 was observed in the dining room visiting with his Responsible Party (RP). The resident's feet were observed hanging off his chair, and his ankles were stuck between the wheelchair foot rests. The RP stated the resident's feet were not supposed to be hanging like that. The RP said, It is not comfortable. He is supposed to have calf supports. On 12/12/22 at 10:52 a.m., an interview was conducted with Staff A, Certified Nurse's Aide (CNA). Staff A stated she did not know about the chair, or if there were interventions related to that. She stated she would let the nurse know. On 12/13/22 at 10:06 a.m., Resident #144 was observed outside the 300 nurse's station hallway. The resident was observed reclined in his chair sleeping. The resident's feet were noted hanging between the footrests of his chair without calf supports. In an interview with Staff A, CNA on 12/13/22 at 10:08 a.m., Staff A stated she noted the resident's feet hanging over the chair. Staff A said, I think he is supposed to have some supports on his legs. Review of a document titled, Active Orders, dated 12/15/22 showed a PT (Physical Therapy) clarification order. PT to treat 3 times/week, x 4 weeks for w/c (wheelchair) management and safety education, as clinically indicated, order date 12/08/22. On 12/13/22 at 12:29 p.m., Resident #144 was observed in the dining room with his RP. The RP stated his feet were hanging off the chair, pointing to his feet. The RP stated she would follow up with PT on the concern. The RP stated the resident fell on [DATE] because he did not have his calf supports. On 12/14/22 at 10:10 a.m., an interview was conducted with the Director of Rehabilitation (DOR). The DOR stated Resident #144 was assessed recently due to a fall. The care plan was updated to ensure calf pads were in place. She stated the resident was declining due to the Parkinson's diagnosis and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105581 If continuation sheet Page 5 of 19 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 105581 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Clearwater 3480 McMullen Booth Rd Clearwater, FL 33761 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 0658 Level of Harm - Minimal harm or potential for actual harm should be closely monitored. The DOR said, He [Resident #144) should have calf pads on to protect his heels and secure his feet for positioning. She stated, The CNAs should be putting the calf pads on. The task is on their [NAME] (meaning a documentation system used by CNAs to document resident's care). The DOR confirmed when she looked at the resident, the calf pads were not on. She stated she would follow-up with nursing. Residents Affected - Few On 12/14/22 at 12:02 p.m., an interview was conducted with the Risk Manager. The Risk Manager confirmed the resident had an unwitnessed fall where he was found on the floor in front of the wheelchair. She stated the resident had an extensive history of falls with recent interventions for alterations of chair, and calf pad supports. The Risk Manager said, At the time of the fall, the resident slid off the chair because his calf pads were not in place. She stated therapy assessed him for positioning and determined calf pads supports should be in place when the resident was out of bed and in his wheelchair. The Risk Manager stated the resident needed the calf pad supports because he was too rigid and would otherwise slide out of the chair. The Risk Manager stated they updated Resident #144's care plan interventions, CNA [NAME] task logs, and notified the primary care nurse to ensure compliance. In an interview with the Director of Nursing (DON) on 12/14/22 at 11:42 a.m., the DON confirmed the calf pads should have been on the resident's chair. She stated they had in-serviced all the CNAs who were working related to proper placement of the calf pads. She stated they had printed visual pictures for the CNAs to reference. (Visual copy was provided). The DON stated education would be on-going for the CNAs who were not at the facility at the time to ensure they were in-serviced prior to working with this resident. On 12/15/22 at 12:09 p.m., an interview was conducted with the Assistant Director of Nursing (ADON) The ADON stated she was responsible for ensuring nursing staff competencies. She stated the CNA should be following care plan interventions and implement as indicated. She stated if the therapist had ordered the calf pads to be in place when the resident was in his chair, the CNAs should follow the plan. The ADON stated she expected the nurses to know the care plan expectations and pass it on to the CNAs. The ADON stated it was expected that the CNAs review the [NAME] prior to each shift and follow it accordingly. On 12/15/22 at 03:20 p.m., an interview was conducted with the DON and Regional Clinical Nurse. They stated they recognized they did not have a plan to ensure the CNAs were aware of new interventions. The DON stated going forward, therapy would print interventions to include pictures, so the CNAs know what was new in the care plan and how to apply the directions accordingly. She stated they had started in-services. The DON said, The plan is to make sure the CNAs know when there are updated interventions and ensure they are able to implement the plan of care. Review of a document titled, Physical Therapy Evaluation and Plan of Treatment, dated 12/08/22, showed treatment approaches may include wheelchair management training, new goal patient will safely sit in the wheelchair 6 to 8 hours without sliding forward in the seat to decrease potential fall from the wheelchair. The assessment summary showed the resident was found on the floor potentially sliding out of the wheelchair patient would potentially benefit from calf panel to decrease sliding forward in the seat. Review of a document titled, Task List Report, showed on functional assistance; calf pad to wheelchair when resident is up in wheelchair. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105581 If continuation sheet Page 6 of 19 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 105581 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Clearwater 3480 McMullen Booth Rd Clearwater, FL 33761 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of a facility policy titled, Nursing/Risk Management- Falls, dated November 2018, showed a purpose to identify and address risk factors associated with resident falls to decrease the likelihood of falls. Procedure: 1. After a resident has fallen a comprehensive risk evaluation will be completed by the interdisciplinary team. 2. The evaluation may include but will not be limited to the following: cause of fall or contributing risk factors if known, review of medications to include pharmacy intermediate medication regimen review, review of any assistive or safety devices currently in use, therapy screen, and recommendations of the team to address fall risk factors. 3. Review and revise care plan with new interventions. 4. Review findings with Resident, Resident Representative and Physician. Review of a facility policy titled, 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 includes 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 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105581 If continuation sheet Page 7 of 19 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 105581 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Clearwater 3480 McMullen Booth Rd Clearwater, FL 33761 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observations, interview, and record review, the facility failed to provide adequate supervision to prevent falls for three (Residents #98, #111, and #514) of eight residents sampled for falls. Findings included: 1. Review of Resident #98's record revealed the resident was admitted to the facility on [DATE], with diagnoses that included Displaced Fracture of Base of Neck of Right Femur, Parkinson's, Generalized anxiety, Dementia, Depression Abnormality of Gait and Mobility, and History of Falling. Review of the Brief Interview for Mental Status (BIMS) dated 12/2/22 revealed a score of 02, which indicated severe cognitive impairment. Observations on 12/12/22 at 10:53 a.m., during the initial tour of the facility, while walking past Resident #98's room, the resident was observed with a low bed and his wheelchair in front of the bed facing the door. The resident was observed with both his knees in the seat of the wheelchair and facing backwards. The resident was hanging over the back of the chair. His torso extended over the back of the wheelchair and his arms were outstretched, touching the bed. The room was noted to have bilateral floor mats next to each side of the bed. At this point, this surveyor stopped the initial tour and notified Staff E Registered Nurse, Unit Manager, who redirected the resident and transferred him from his wheelchair to his bed. An interview with Staff E on 12/12/22 at 10:59 a.m., revealed the resident wanted to go to bed and was a high fall risk, with behaviors. An interview with the resident on 12/12/22 at 11:00 a.m., revealed he was trying to get in bed all day and no one would help him. The resident was unable to understand the use of the call bell. A review of the resident's transfer form (3008) dated 11/16/22 revealed the resident had a risk alert for falls. A review of the resident's evaluation of fall risk dated 11/16/22 revealed a score of 13 (High Risk) A review of the resident's evaluation of fall risk dated 12/6/22 revealed a score of 19 (High Risk) A review of the behavior monitoring on the Medication Administration Record (MAR) for 12/12/22, day shift, revealed no documentation of the behavior observed on this day. A review of the progress notes from 11/16/22 to present, revealed no documentation of the observations noted on 12/12/22. A review of the resident's record and the facility's incident reports revealed the following: 12/14/22 19:46 (7:46 p.m.)- Incident report- Resident found on floor lying in supine position; head positioned (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105581 If continuation sheet Page 8 of 19 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 105581 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Clearwater 3480 McMullen Booth Rd Clearwater, FL 33761 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 0689 Level of Harm - Minimal harm or potential for actual harm -Incident Report 12/6/22 22:58 (10:58 p.m.)-resident on floor next to wheelchair in living room wants to go home. Found on floor in dayroom; not witnessed; Resident continues with impulsive behaviors; POC updated; Engagement with activities; dining with peers. -Change in condition dated 12/6/22 Residents Affected - Few -Incident note 12/5/22 13:42 1:42 p.m.) Resident found on floor in tv room after breakfast. no injuries noted, neuro check wnl [within normal limits]. when assisting back to w/c [wheelchair] resident stated 'hey I'm comfortable.' -Incident report 12/5/22 8:40 a.m.- Collaborative efforts with IDT [Interdisciplinary Team] to address continued behaviors resulting in change of plane; Resident continues to be frequently monitored; 15 minute checks; Staff continue to anticipate Residents needs; Medication profile reviewed; Nicotine patch reordered; Alternate w/c cushion provided. -Change in condition 12/4/22 -Nursing Note 12/4/22 01:00 (1:00 a.m.)-Resident found by CNA on the floor in front of the bathroom. Fall unwitnessed. Resident had gotten out of bed with scoop mattress, put himself in his wheelchair without calling for assistance. Non skid socks on resident. Resident on the floor of room with bathroom door closed and his pants down just above his knees. resident assessed and found to have no visible injuries. Vital signs stable. Stated some back pain, medication given. Resident cleaned up and returned to bed. -Incident Report 12/4/22 0100 (1:00 a.m.)-POC updated :Frequent monitoring, Alternate wheelchair. -Change in condition 12/1/22 17:00 (5:00 p.m.) -SBAR (Situation, Background, Assessment, Recommendation) 12/1/22 17:00 (5:00 p.m.)-resident was observed sitting on floor in front of wheelchair no injury noted no c/o pain or discomfort resident assisted off floor by staff rom [Range of motion] wnl neuro wnl. no new orders. -Incident Report 12/1/22 18:07 (6:07 p.m.) Resident observed sitting on floor in front of wheelchair by recliner was in bed climbed out of bed was walking around room. Resident stated, 'I was going over there.' 12/2/22, Historical Falls Palm program identified by magnet; Common areas; Toileting management; psychiatric consultation; manual wheelchair safety adjustments; Clinical review Lab Monitoring; 15 minute checks in progress; additional manual wheelchair adjustments. -Care plan related to falls -Assist resident to common areas for increased visualization; and to maximize socialization initiated 11/21/22 with revision 12/2/22 -Change in condition 12/1/22 13:15 (1:15 p.m.) -Nursing Note 12/1/22/13:20 (1:20 -p.m.) -Resident was seen sitting on his bottom laying slightly on his back in front of his recliner. The wheelchair was seen flipped on its side. The client stated he was trying to go to bed. The call bell was not on and he had removed non-skid socks. therapy and CNA helped his writer assist him into his wheelchair and placed in common areas. No noted new injuries. Hand grasps WNL and vitals stable at this time. Director of Quality assurance notified of incident. Family and physician notified and neuro checks started per facility protocol. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105581 If continuation sheet Page 9 of 19 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 105581 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Clearwater 3480 McMullen Booth Rd Clearwater, FL 33761 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few -Incident report 12/1/22 13:15 (1:15 p.m.)- POC reviewed: Psychiatric consult for re-evaluation; Medication management. -Change in condition 11/27/22 -Incident note 11/27/22 11:39 a.m. -Called to room, resident on floor lying on his back. confused stating stating I was trying to get my chair. skin tear to right upper shin. able to move all extremities pupils equal and reactive to light. Helped up to w/c brought to nurses station. -Incident report 11/27/22 11:32 a.m. -Care plan related to fall with interventions Anti tippers to manual wheelchair initiated 11/28/22, revised on 12/12/22 -Care plan related to fall with intervention related to falls Drop Seat to manual wheelchair -Incident Report 11/21/22 22:32 (10:32 p.m.) -Resident sitting on floor next to wheelchair wearing non skid shoes, pants and shirt. resident stated he wanted coffee and his pants from laundry.-Awaiting return call from interested parties to gain a greater perspective on usual and customary daily activities; POC updated: Scoop Mattress; Common areas. -Fall care plan with revised interventions include Scoop mattress, initiated 11/21/22; Assist to common areas for increased visualization; and to maximize socialization. -Fall care plan with revised intervention floor mats at bedside while in bed initiated 11/21/22 -Change in condition 11/20/22 -Progress note 11/20/22 01:45 1:45 a.m. -Resident found on the floor in his room by the door. Fall unwitnessed. Stated he was looking for a phone to call his boss. Vital signs stable. No visible injuries. Notified Physician, no new orders given. Resident assessed and declined returning to bed, requested to sit in his wheelchair. Resident assisted to wheelchair by CNA and nurse. -Incident report dated 11/20/22- indicated Resident linens on bed wet with urine and a mess. Identified as a fall risk with palm magnet placement outside door; POC update: floor mats; Toileting management -Care plan related to falls- with intervention initiated 11/20/22, Toileting management Assist Resident to the bathroom upon rising; before and after meals; at bedtime; and frequently throughout the day. Observations on 12/14/22 at 08:19 a.m. revealed the resident to be calm, navigating hallways independently in his wheelchair, requesting assistance to go to his room. An interview on 12/14/22 at 08:38 a.m. with Staff S, LPN revealed the resident was a fall risk and staff had to constantly check in on him. She reported the resident should always be in line of sight, which had been in place for some time. An interview on 12/14/22 at 08:46 a.m. with Staff T, CNA, revealed the resident was very confused (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105581 If continuation sheet Page 10 of 19 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 105581 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Clearwater 3480 McMullen Booth Rd Clearwater, FL 33761 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and was a fall risk. She reported after his meals she would toilet him and would put him down to rest. She reported he was on every 15 minute checks since the weekend. An interview was conducted on 12/15/22 at 11:25 a.m., with the Nursing Home Administrator (NHA) and the Risk Manager. The Risk Manager reported the fall last night, 12/14/22, was an unwitnessed fall. The Risk manager reported the resident was on 15 minute checks from 12/4-12/6 only. She reported all staff were aware the resident was a high fall risk and everyone looked out for him and everyone knew he was impulsive. Resident was on frequent supervision and moved to the front hall for higher traffic supervision. The Risk Manger and NHA were unaware of the incident this surveyor witnessed on Monday 12/12/22. An interview on 12/15/22 at 12:28 p.m. with the NHA revealed nursing reports any concerns to the morning/clinical meeting, this was where they would discuss behaviors and possible interventions. She reported the observation reported to staff on 12/12/22 should have gone to the risk manager, and should have been documented. An interview on 12/15/22 at 12:30 p.m., with the DON, revealed if the resident had a change in behavior, a note would be written and the DON would pull a 24 hour report and would discuss the concern in the clinical/stand up meeting. She reported staff were trained in this process during orientation. Review of the facility policy titled Nursing/Risk Management-PALM Program with an effective date of October 2014 and a revised date of November 2018 revealed the following: 3. Team intervention which may apply to PALM Program participants include the following suggested interventions: -in view of staff when OOB 2. An observation was made, on 12/12/22 at 11:28 a.m., of Resident #514 sitting in the common area of the 400-unit, across from the nursing station. The residents' left arm was wrapped with an elastic bandage, was edematous with purple-blue discoloration, and resting on an over-the-bed table. The resident appeared to be mildly confused and stated she had broken her arm but not at the facility. An interview was conducted at 10:14 a.m. on 12/13/22, with Resident #514 and a family member. The family member reported the resident had fallen on Sunday (12/11/22) and the ulna bone was broken. The cotton padding and elastic bandage was lying on the residents' bedside dresser. The family member reported the resident had kept picking at it and did not know if the resident had taken it off or if they (the facility) had. The family member stated the resident had fallen three times and had been moved closer to the nursing station for staff to watch her. On 12/14/22 at 9:02 a.m., Resident #514 was observed sitting in bed, feeding self, and wearing a wrist brace on her left arm with a white border dressing to left elbow. The resident stated, It's absolutely miserable (the brace). During an interview on 12/14/22 at 11:02 a.m., Staff G, Registered Nurse (RN) stated the resident was in therapy and the facility was doing 15 minutes checks. The staff member reported the resident had attempted to stand and get up last night so the facility ran STAT labs which included a complete blood count and a comprehensive metabolic panel. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105581 If continuation sheet Page 11 of 19 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 105581 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Clearwater 3480 McMullen Booth Rd Clearwater, FL 33761 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #514's admission Record revealed the resident was admitted on [DATE]. The record included diagnoses not limited to unspecified Encephalopathy, site not specified urinary tract infection, not elsewhere classified senile degeneration of brain, and age-related osteoporosis with current pathological fracture. The Incident Log, dated 12/15/22, identified Resident #514 had a witnessed fall on 12/2/22, and unwitnessed falls on 12/11 and 12/12/22. The Situation, Background, Assessment and Recommendation (SBAR), dated 12/2/22, identified Resident #514's change in condition was related to a fall. The form identified mental status, functional status, or pain had changed from baseline, that the resident's behavior was not clinically applicable, and the resident had suffered a skin tear. The primary care clinician (PCC) recommended to increase oral fluids and other (which was described). The nursing note, attached to the SBAR, did not describe the incident. An electronic Change in Condition note (eINTERACT), dated 12/2/22, indicated Resident #514 had a fall, suffered a skin tear, was accompanied by significant pain or bleeding, and was positive for a Urinary Tract infection (UTI) on admission. The note indicated the resident was seen sitting on [buttocks] outside of the resident's room in the doorway. The resident notified staff of a fall in the bathroom. The resident suffered 5 skin tears to the right upper extremity. The SBAR, dated 12/11/22, identified Resident #514 had a change in condition related to Trauma (fall related or other). The evaluation indicated the resident had increased confusion or disorientation, falls (one or more), and discoloration of the skin with no pain. The PCC recommended to send to the Emergency Department (ED) for evaluation (eval) and treatment (tx). A progress note identified that Resident #514 had suffered a fall on 12/11/22, transferred to the hospital, mentation was not at residents' baseline, and a Urinalysis had been requested from the physician. The resident had returned with left arm splinting. A record review of an eINTERACT note, dated 12/11/22 and completed on 12/13/22, revealed Resident #514 had a fall-related trauma. The note indicated the nurse was alerted by the Certified Nursing Assistant (CNA) that the resident was lying in a supine position on the floor. An order had been obtained to send to ED for eval. and tx. A SBAR, dated 12/12/22, indicated Resident #514 had a fall and this condition, symptom, or sign has occurred before. The evaluation of the resident indicated the resident had increased confusion or disorientation, one or more falls and no pain. The behavioral, respiratory, cardiovascular, abdominal, urinary evaluations were not clinically applicable to the change in condition being reported. The resident suffered a skin tear. The recommendations from the PCC indicated neuros per policy, continue frequent monitoring, (and) pending lab results. A progress note, dated 12/12/22 at 12:13 p.m., described Resident #514 was seen sitting by the nursing station then seen in front of wheelchair by the nursing station with the phone hanging by the cord off of the desk. Labs and Urinalysis (UA) were pending. The one evaluation of Fall Risk included with Resident #514, which was completed after the residents second fall on 12/11/22 identified the resident had 1 or 2 falls in the past month, had impaired safety awareness, and a recent fracture. The evaluation indicated the resident used a walker, had an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105581 If continuation sheet Page 12 of 19 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 105581 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Clearwater 3480 McMullen Booth Rd Clearwater, FL 33761 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 0689 unsteady gait, no self-release or safety device were ordered, and the resident was a high risk for falls. Level of Harm - Minimal harm or potential for actual harm The acute facilities radiology results, on 12/11/22 at 11:08 a.m., for Resident #514 identified a comminuted and displaced intra-articular distal radial fracture and minimally displaced ulnar styloid fracture. Residents Affected - Few The review of Resident #514's care plan included a focus, initiated on 11/30/22 and revised on 12/2/22, that identified the resident was At risk for falls related to: history (Hx) Falls, bilateral lower extremity (BLE) weakness, Osteoporosis, Chronic Pain Syndrome, Bursitis Multiple areas, Encephalopathy, (and) Advancing Age. The goal was Will strive to have falls and/or injuries minimized thru management of risk factors while maintaining independence and quality of life through the review date. The interventions included: - Observe for unsafe actions and intervene as needed, initiated 11/30/22. - Observe for unsafe ambulation, initiated 11/30/22. - Check for toileting needs, initiated 11/30/22. - Keep adaptive equipment within reach, initiated 11/30/22. - Physical Therapy (PT) and Occupational Therapy (OT) to screen as needed (prn), initiated 11/30/22. - Place items used in easy reach i.e. Water, telephone, (and) call lights, initiated 11/30/22. - Encourage appropriate footwear, initiated 11/30/22. - Four wheeled walker with seat, initiated 12/2/22. - Palm Program, initiated 12/2/22. - Reinforce utilization of call light; (Resident) able to return demonstration, initiated 12/2/22. - Frequent Observation: 15-minute monitoring, initiated 12/11/22. - Change of room assignment for increased visualization, initiated 12/12/22. The observation logs, provided by the facility for Resident #514 identified they began on 12/13 and continued through 12/15/22. The Director of Quality Assurance (DQA) stated, on 12/15/22 at 9:13 a.m., the facility had identified an increase in falls, updated on 12/6/22. The DQA stated the facility had initiated a fall committee which included a nurse from each unit and an aide from each shift, so each shift could cooperate, implement measures, and communicate with agency and part-time staff. She identified the facility had implemented a huddle. On 12/15/22 at 1:38 p.m., the Risk Manager/DQA said regarding Resident #514's fall on 12/2/22, she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105581 If continuation sheet Page 13 of 19 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 105581 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Clearwater 3480 McMullen Booth Rd Clearwater, FL 33761 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few had collaborated with the son and the resident had demonstrated an acute decline in executive decisions. She stated the fall on 12/2/22 was unwitnessed and the resident had reported sliding down the shower curtain while in the bathroom, putting self on towel, and sliding to the door entrance. The family reported the resident did better with a 4 wheeled walker (which family brought to the facility). The DQA stated staff enforced the use of call light and assistive device. The DQA said cognitive changes had been noted with Resident #514 on the morning of 12/11/22. She was brought to the nursing station, did not want to stay there, continued to ambulate without assistance, and was found on the floor without the walker. When the resident went to the hospital the facility did a room change. The resident came back with a soft cast for a wrist fracture. The DQA stated the care plan was updated to keep the resident in common areas. The DQA said, on 12/12/22 Resident #514 stood up at the nursing station while on the phone with daughter and ended up with a skin tear. She stated the nurse requested a urinalysis and labs from the physician, did a clinical review, asked the physician to look at medications, psych to see resident, and ordered labs. She reported the following was initiated: Pain Management consult following the third fall, anti-roll backs and anti-tippers on wheelchair, and leg rests were removed. Resident #514 fell on [DATE] when in the common area of the unit and per the family member continued to have poor safety awareness (toileting self during the night of 12/12 - 12/13/22) despite being moved to a room closer to the nurses station and being brought to the common area for visualization. 3. Resident # 111's admission Record revealed he was admitted to the facility on [DATE] with a primary diagnosis of Parkinson Disease. A review of the Quarterly Minimum Data Set, dated [DATE], Section C titled Brief Interview Mental Status (BIMS), revealed Resident #111's BIMS score was a 7 which indicated moderately impaired cognition. A review of The Nursing Care plan dated 10/20/2022, showed Resident # 111 was at risk for falls. Care Plan interventions for Resident #111 showed he should be observed for unsafe ambulation and unsafe actions and intervene as needed. A record review of The Change in Condition note dated 12/14/2022, showed Resident #111 was evaluated for a fall. A record review of the nursing progress note dated 12/11/2022, showed Resident # 111 had a unwitnessed fall in the dayroom by the Christmas tree. On 12/15/2022 at 8:47 a.m., an interview was conducted with the Risk Manager. The Risk Manger said Resident # 111 had an unwitnessed fall in the dayroom on 12/14/2022, he was trying to transfer out of his wheelchair into another chair in the dayroom. On 12/15/2022 at 8:47 a.m., an interview was conducted with the Director of Nursing, DON. The DON said Resident #111 had an unwitnessed fall on 12/11/2022 and 12/14/2022, in the dayroom. The DON said the dayroom was a high traffic area and it was not supervised all the time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105581 If continuation sheet Page 14 of 19 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 105581 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Clearwater 3480 McMullen Booth Rd Clearwater, FL 33761 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interview, and policy review, the facility failed to label and date opened food and maintain a clean, sanitary kitchen in accordance with professional standards for food service safety. Residents Affected - Some Findings: Observation on 12/12/2022 at 10:44 a.m. , revealed packets of food, trash, and a wash rag underneath the shelves on the food pantry room floor. A molded pan of gravy was found underneath the shelf with food stored on the shelf inside the refrigerator on the floor. Observation on 12/14/2022 at 10:00 a.m., was conducted in the nourishment room on the C and D nursing wings. Inside the nourishment room on the D wing was an opened, unlabeled, and undated [brand name] meatball bag left inside the freezer. Inside the nourishment room on the C wing was two boxes of ice cream and two frozen dinner boxes unlabeled and undated. On 12/18/2022 at 10:00 a.m., an interview was conducted with Staff L, the Certified Dietary Manager, CDM. The CDM said the nourishment rooms are cleaned, stocked, and maintained by designated culinary aids every day of the week. The CDM said the dietary staff made sure the food inside the refrigerator and freezers were dated and labeled correctly. Food that is not labeled and dated should not be left inside the freezer or refrigerator. The CDM said he could see there was undated and unlabeled food, but he would not throw it out because he hated to waste food. On 12/14/2022 at 4:21 p.m., an interview was conducted with the Nursing Home Administrator, NHA. The NHA said her expectation for food stored inside the nourishment rooms freezer and refrigerators should be labeled and dated and only used for the residents not the staff. The NHA said the dietary staff restocked the refrigerator every afternoon and should check to see if there were any food items unlabeled and undated; they should throw out any items they found inside the freezer or refrigerator not dated our labeled. Record review of the facility's policy titled, Food Storage, dated October 2014, showed that food storage areas shall be maintained in a clean manner at all times. Procedure 2. Shelves, racks, dollies, or other surfaces used for food storage should facilitate thorough cleaning. Record review of the facility's policy titles, Resident Personal Food, dated October 2014, showed items brought into the facility will be stored unsanitary conditions. Procedure 2. Labeled and dated perishable items may be stored under refrigeration in thee nursing unit consistent with standards of food storage. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105581 If continuation sheet Page 15 of 19 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 105581 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Clearwater 3480 McMullen Booth Rd Clearwater, FL 33761 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to implement an effective Infection Control program related to the unsanitary environment of the laundry room related to personal food items and belongings sitting on same folding counter as resident linen, failed to ensure two (Staff H and J) direct care staff members had fingernails that were per Centers of Disease Control and Prevention guidelines were of an appropriate length, and failed to ensure Seven (Residents #86, #119, #23, #112, #37, #58, and #42) out of eight residents receiving oxygen therapies. Residents Affected - Some Findings included: 1. During an interview with the Infection Preventionist (IP) on 12/14/22 at 11:05 a.m., she stated the facility followed the Center of Disease Control and Prevention (CDC) recommendations/guidelines. She stated she had been to the laundry area earlier that day. An observation was conducted on 12/14/22 at 12:28 p.m., with the IP of the facility's laundry processing area. Staff K, Laundry Aide, was standing against the laundry folding counter and stated she had just returned from lunch. In the corner of the laundry counter, which had folded linen and hospital gowns on top of it, was a plate of cookies, an opened bag of cheesy puffed treats, a cell phone, and a key ring with keys. Immediately following the observation of the laundry processing are, the IP confirmed food items should not be on the folding counter. The policy - Handling Linens to Prevent and Control Infection, effective December 2020, identified that written policies and procedures are needed and should include training for staff who will handle linens and laundry. The policy provided by the facility did not address keeping personal items stored with facility linens. The CDC guideline, Appendix D - Linen and laundry management: Best Practices for Environmental Cleaning in Healthcare Facilities: in RLS, reviewed: March 27, 2020, (https://www.cdc.gov/hai/prevent/resource-limited/laundry.html), identified that Best practices for management of clean linen: Sort, package, transport, and store clean linens in a manner that prevents risk of contamination by dust, debris, soiled linens or other soiled items. An observation was made on 12/13/22 at 11:40 a.m., of Staff H's, Certified Nursing Assistant (CNA), fingernails which extended approximately 1/2 - 3/4 inches past the fingertip. The fingernails were painted white and black, the fourth finger on right hand was white with black raised jewels and the fourth finger on left hand was painted black with white raised jewels. The staff member stated I lost one indicating a shorter nail on the middle finger of left hand. She stated she used double gloves so not to break through. On 12/14/22 at 8:44 a.m., Staff H was observed, on the 400 hall, with the continued long fingernails. On 12/13/22 at 11:59 a.m., Staff J, CNA, was observed propelling a resident in a wheelchair from the residents room. The Staff J's fingernails were thick, painted pink, and extended approximately 1/4-1/2 above the fingertip. Staff J stated, they're long. The Infection Preventionist (IP) reported, on 12/14/22 at 11:05 p.m., that fingernails for direct (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105581 If continuation sheet Page 16 of 19 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 105581 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Clearwater 3480 McMullen Booth Rd Clearwater, FL 33761 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 - Some care staff should not be more than 1/4 past fingertip and if looking at back of hand should be barely seen. She stated that rhinestones could cause a problem and would have to check the protocol for fake and painted fingernails. The facilty policy - Dress Code Policy, effective October 1, 2014 and revised September 2, 2021, indicated that the purpose was to provided the very best service and care possible to out resident/patients. Our manners of dress, grooming, and personal cleanliness speak for us at Palm Garden when we are in contact with residents, family members, guests, and co-workers. The detail #8 identified that Hair and nails should be clean and groomed. Nail length should not be so long as to interfere with work duties. The CDC guideline - Water, Sanitation, and Environmentally Related Hygiene (WASH), last reviewed on June 15, 2022, (https://www.cdc.gov/hygiene/index.html), indicated that Appropriate hand hygiene includes diligently cleaning and trimming fingernails, which may harbor dirt and germs and can contribute to the spread of some infections, such as pinworms. Fingernails should be kept short, and the undersides should be cleaned frequently with soap and water. Because of their length, longer fingernails can harbor more dirt and bacteria than short nails, thus potentially contributing to the spread of infection. The CDC guideline - Hand Hygiene in Healthcare Settings, last reviewed on January 8, 2021, included the following: - Germs can live under artificial fingernails both before and after using an alcohol-based hand sanitizer and handwashing; - It is recommended that healthcare providers do not wear artificial fingernails or extensions when having direct contact with patients at high risk (e.g., those in intensive-care units or operating rooms); - Keep natural nail tips less than ¼ inch long. On 12/14/22 at 9:06 a.m., an observation was made of Resident #86 wearing a nebulizer mask while lying in bed, the nebulizer machine could be heard from the hallway. The observation revealed, on 12/14/22 at 9:08 a.m., a steady amount of aerosol coming from the residents' nebulizer mask, the resident stated it was just a nebulizer. The nebulizer machine could be heard stopping, as this writer left the residents' room at 9:08 a.m. on 12/14/22 and from the hallway an observation identified that the resident had removed the nebulizer mask. On 12/14/22 at 9:15 a.m., Staff I, Licensed Practical Nurse (LPN), stated a nebulizer treatment could take between 10-15 minutes depending on the (nebulizer) machines' compressor. Staff I stated, what did she do, take it off? The LPN entered Resident #86's room, on 12/14/22 at 9:21 a.m., and picked up the nebulizer mask from the top of the bedside dresser, looked at it, and placed it into the plastic bag hanging from the bedside dresser. The nurse removed the mask and identified a clear liquid remained in the nebulizer medication cup. The nurse left the residents' room on 12/14/22 a short time later and stated that the nebulizer had been rinsed and dried. During an interview on 12/14/22 at 11:05 a.m., the Infection Preventionist (IP) stated that nebulizer/oxygen/continuous positive airway pressure (cpap) equipment should be cleaned, dried, then put in a bag. The oxygen equipment was changed weekly, stay in plastic bag, and not on (resident) dresser. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105581 If continuation sheet Page 17 of 19 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 105581 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Clearwater 3480 McMullen Booth Rd Clearwater, FL 33761 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 - Some The facility policy - Cleaning and Disinfecting Nebulizer, effective December 2020, indicated that Cleaning and disinfecting of nebulizer machine will be completed based on the manufacturer's recommendations. The procedure portion of policy included the following instructions: - 1. Follow manufacturer's guidelines for cleaning and disinfecting of machine and equipment. Specific instructions may vary with the manufacturer. - 2. Consult with the manufacturer to determine which cleaning procedures. - 3. Apply clean gloves. - 4. Disassemble the nebulizer by removing the cup and mask or mouthpiece. - 5. Thoroughly clean all visible soil or organic material from the cup, mask or mouthpiece before cleaning and disinfection. - 6. Follow manufacturer's recommendations for cleaning instructions, frequency, disinfection, and replacement (i.e. Use warm water and a mild dish detergent to wash the nebulizer parts. Rinse them thoroughly to remove all soap and residue. Allow the parts to air-dry on a clean surface). - 7. Shake off any excess water and allow the cup to air dry on a clean surface. Do not place the nebulizer parts directly on a contaminated surface. 2. On 12/12/22 at 09:59 a.m. Resident #58 was observed in her room sitting in her wheelchair. An oxygen concentrator was noted behind her chair. The resident's oxygen nasal cannula was observed on top of her nightstand, laying above magazines and other objects. The tubing was noted not bagged and exposed to the elements. A clear storage bag was noted by the side of the nightstand, dated 12/6/22. Photographic evidence was obtained. Review of the Electronic Medical Record (EMR), showed Resident #58 was admitted to the facility on [DATE] with a diagnosis to include shortness of breath. The resident's active physician orders dated 12/15/22, showed to use oxygen PRN (as needed) to keep O2 Saturation above 90% every shift, order date 2/7/22 and to change and date all oxygen tubing every week when in use, order date 1/27/22. On 12/12/22 at 10:13 a.m., Resident #42's CPAP (Continuous Positive Airway Pressure) machine was observed on the resident's bedside table. The mask was laying on top of a container full of personal care items. The tubing and mask were not bagged. Photographic evidence was obtained. A review of the EMR showed Resident #42 was admitted to the facility on [DATE] with a diagnosis to include obstructive sleep apnea. The resident's active physician orders dated 12/15/22 showed CPAP settings for every evening and night shift, order date 8/26/22. The orders did not indicate how the mask or tubing should be stored, or how often they should be cleaned or changed. On 12/12/22 at 10:24 a.m., 12/13/22 at 12:06 p.m., and 12/14/22 at 9:19 a.m., Resident #37's nebulizer machine was observed on her nightstand. The mask was positioned on top of the machine, which was also opened to the elements. Resident #37 confirmed she used it for her nebulizer treatment. The nebulizer mask and machine were exposed to the elements during 3 of 3 days of survey. A review of active physician orders for Resident #37 showed Albuterol sulfate nebulization solution (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105581 If continuation sheet Page 18 of 19 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 105581 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Clearwater 3480 McMullen Booth Rd Clearwater, FL 33761 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 2.5 MG (milligram)/3 ML(milliliters) 0.083% 3 ml inhale orally via nebulizer every 4 hours as needed for SOB (shortness of breath). The orders did not indicate how the machine, mask or tubing should be stored, or how often they should be cleaned or changed. Residents Affected - Some On 12/14/22 at 5:40 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated respiratory equipment should be stored in a bag and dated. It should not be left out for sanitary reasons. She stated the concern was brought to her attention earlier, and they have started in-services. The DON stated their expectation is to ensure equipment is stored appropriately. On 12/15/22 at 3:24 p.m. an interview was conducted with the Regional Clinical and the DON. They stated they had already started education, which included to follow the policy related to cleaning, and maintaining equipment in a sanitary manner. The DON said, the policy might not specifically state bagging it does address appropriate storage though. 3. An observation was made on 12/12/22 at 1:18 p.m. in the room of Resident #112. The resident's nebulizer mask was sitting on her bedside table uncovered. On 12/13/22 at 11:44 a.m. Resident #112's nebulizer mask remained uncovered on the table. (Photographic evidence obtained.) A review of admission records indicated Resident #112 was admitted on [DATE] with diagnoses including chronic respiratory failure and chronic obstructive pulmonary disease (COPD.) A review of Resident #112's orders revealed an order for Ipratropium-Albuterol Solution 0.5-2.5 mg/3 ml. 3 ml two times a day for shortness of breath. An observation was made on 12/13/22 at 10:09 a.m., in the room of Resident #119. The resident's nebulizer mask was sitting on the bedside table uncovered. The resident stated the mask stayed that way and did not get put in a bag. (Photograph unable to be obtained due to location of the resident.) A review of admission records indicated Resident #119 was admitted on [DATE] with diagnoses including COPD and chronic diastolic heart failure. A review of orders revealed an order for Albuterol Sulfate Nebulization Solution 2.5mg/3 ml. 3 ml inhale orally every six hours as needed for shortness of breath/wheezing. An observation was made on 12/13/22 at 11:44 a.m., in the room of Resident #23. The resident's nebulizer mask was sitting on the bedside table uncovered. An additional observation was made on 12/14/22 at 10:43 a.m., in the room of Resident #23. The resident's nebulizer mask remained uncovered. The resident stated it was kept that way. She said she wondered because at home her nebulizer went in a box, but this one never was. A review of admission records indicated Resident #23 was admitted on [DATE] with diagnoses including COPD. A review of orders revealed an order for Ipratropium-Albuterol Solution 0.5-2.5 mg/3 ml. 3 ml four times a day for COPD. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105581 If continuation sheet Page 19 of 19