Inspection·January 16, 2020

F 0572 3) Level of Harm - Minimal harm or potential for actual harm Welcome Information Booklet 4) Residents Affected - Few Patient (Guest) and Resident State Rights. Record review of the admission Policy, undated, revealed, The Admissions Team will follow facility policies regarding admissions. On 01/14/20 at 8:45 a.m., during an interview, Resident #89 stated, you can check anything you want but I don't think we got one. My son would have had it. Observation revealed there wasn't an admission packet in room. An interview was completed on 01/14/20 at 1:57 p.m. with the Director of Guest Services (DGS). DGS stated that they provide residents with a packet they take with them, which includes the information welcome booklet, resident rights, copy of the ombudsmen pamphlet, pet policy, all the different practitioners, and dentists. This package also includes a rate sheet. DGS stated the admission agreement does require a signature and that residents have a right to a copy if they wish. DGS stated that facility does keep a hard copy of the signed admission agreement which is also scanned into their Point Click Care system. DGS acknowledged that they did not have a signed copy of the admission agreement from the Resident or POA. DGS acknowledged that they did not know about the request for a meeting from the Resident's POA. DGS acknowledged that the date to have the paperwork signed was on 12/30/19 during the Partners in Care Meeting with the Resident's POA present. The Partners in Care (PIC) Meeting consists of the interdisciplinary team that will discuss the discharge plan, go over medication, meet and greet the family members, and orient the Resident to the department. Facility staff that usually attends the PIC meeting will be a member of Quality Assurance, a Unit Manager, a social worker, and a member of dietary. Record review of the Partners in Care Meeting documentation, signed and dated on 12/30/19, revealed, code status verified- son @ bedside. Photo evidence of documentation included. Interview on 01/14/20 at 2:32 p.m. with the Unit Manager Staff H, Registered Nurse (RN), said that they document anything that occurs in the PIC meeting onto the PIC documentation. They discuss information related to discharge and introduce the Resident to the various staff members. Staff H revealed that they don't do anything with the admission package during the PIC meeting. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105591 If continuation sheet Page 2 of 14 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 105591 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/16/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Tampa 3612 E 138th Ave Tampa, FL 33613 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, policy review, and interviews, the facility did not ensure the advance directive status, related to a DNRO (do not resuscitate order), was clearly identified in the medical record for two (#80 and #89), of eight residents reviewed. Findings included: 1. Resident #80 was admitted to the facility on [DATE] with a diagnosis of dementia, according to the facesheet in the admission record. During the record review for Resident #80, a telephone order, dated [DATE], was discovered under the Advance Directive tab in the medical record at the nurse's station. The order summary indicated Resident #80 was a full code. However, further review of the record revealed a yellow Florida Do Not Resuscitate Order, dated [DATE], and signed by the resident and her physician. It was located directly behind the telephone order. Upon review of the electronic physician's orders, an order, dated [DATE], indicated Resident #80 was a DNR. Further review of the same electronic orders, reflected an order, dated [DATE], Resident #80 was a full code. Both orders were marked Active. *Photographic evidence was obtained. The advance directives care plan, dated [DATE], was also reviewed, and revealed the following: Resident #80 does not have advanced directives: She is a DNR code status. A review of the form, Acknowledgement of Advance Directives, dated [DATE], and signed by Resident #80, revealed Resident #80 had a Florida DNRO, and the resident's husband was to bring it in. Review of the Quarterly Advance Directive Review, dated [DATE], reflected the Florida DNRO was provided on [DATE], and was signed by Resident #80's husband on [DATE]. Review of progress notes in the medical record, dated [DATE], revealed a nurse's note that indicated Resident voices desire to be a DNR, husband is aware of her wishes. Witnessed with Unit Manager. A subsequent note indicated Resident #80 signed her DNR forms and made her wishes known that she does not wish to be resuscitated if her heart was to stop. Husband is also aware of resident's wishes. The physician gave orders for DNR, and signed the DNR form. On [DATE] at 3:01 p.m. an interview was conducted with the SSD (social services director) and SSA (social services assistant). The SSD said two nurses go in as soon as they can, the day of admission, and they establish if the resident is DNR or full code. If the resident is DNR, the nurses write the order. Social services follows up on the the Florida DNRO. When the Florida DNRO is signed, social services puts it in the doctor's book. Social services follows up checking on the Florida DNRO, to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105591 If continuation sheet Page 3 of 14 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 105591 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/16/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Tampa 3612 E 138th Ave Tampa, FL 33613 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few make sure the physician has signed it. The SSD said that happens as soon as social services is in the building. If the resident came on a Friday or weekend, then social services would address it Monday. She also confirmed a care plan should be initiated for CPR or DNR. The SSA said social services creates the care plan. The SSD said they have to make sure everything is in place before they create it. They don't put the care plan in there until they know it is correct. Social services puts in the care plan when they know everything is complete. The nurses are inserviced to know to look for that order in the chart, the hard chart. The chart they have access to on the floor. The residents are a full code if they're not a DNR. The order will either say CPR or DNR. The nurses wouldn't do anything until they pulled that chart and verified the order. It is actually a telephone order. The nurses take the order, put it on the chart, and then a copy of the order is placed in the physician's book for him to sign. She said she doesn't know how that piece (the electronic record) is handled. That is definitely a nursing question. Two nurses have to verify the DNR order. The paper isn't necessarily on the chart until the doctor signs it. The SSA said the yellow form is for transport. The SSD said that DNR order is effective once the physician is notified, after the two nurses verified that is the patient's wish. The policy review, Advance Directive and Code Status, dated [DATE], revealed the following information: Advanced Directive Code Status Guidelines: The center will perform CPR on residents that do not have physician's orders for Do Not Resuscitate DNR. However, the Center will support the right of every resident to make decisions, including the right to accept or decline cardiopulmonary resuscitation in the event of cardiac arrest. Procedure 1. Upon admission the nurse completing the admission assessment will ascertain the resident's wishes related to code status (CPR or DNR) with a second nurse witness. If the resident is incapacitated or is unable to communicate their wishes regarding code status, reasonable efforts will be made to contact the designated responsible party or surrogate medical decision maker to ascertain the resident's desired code status. The code status for the resident will remain CPR until contact is made to determine the resident/responsible party's wishes. 2. Two nurses will witness and will document the resident/responsible party's code status wishes in the electronic health record (EHR). 3. The nurse will contact the resident's attending physician/extender, to notify the attending physician/extender of the resident/responsible party's wishes related to code status and an order for CPR or DNR will be obtained, and immediately entered into the EHR. In the event of a DNR order received via telephone, two nurses shall witness a verbal telephone order by each nurse making a progress note in the EHR documenting the verbal/telephone order by each nurse making a progress note in the EHR documenting the verbal/telephone order for DNR, and place copy of order in advance directive section of the chart. 4. The code status order will be documented in the EHR and will serve as the primary source of validation of code status should a resident be found unresponsive. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105591 If continuation sheet Page 4 of 14 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 105591 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/16/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Tampa 3612 E 138th Ave Tampa, FL 33613 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 5. The state of Florida DNR form (DH 1896) found in FL statute 401.45, we use to communicate a resident's DNR code status wishes to 911/ emergency medical services (EMS) should the resident be found unresponsive. If executed, the state of Florida DNR form (DH 1896) will be scanned into the EHR under miscellaneous section. 6. If the resident/responsible party wish to choose a DNR code status, the resident/responsible party will sign and date the state of Florida DNR form DH 1896. This can be signed and dated in person, via fax, or scanned in email, for a resident representative not present. 7. After signatures have been obtained from the resident/responsible party, the resident's attending physician will sign and date the state of Florida DNR order form (DH 1896), either in person at the time of the order, in person at their next visit to that record, or via fax/scanned and email. 8. If a resident was found unresponsive the EHR must be accessed to determine the code status order. For any resident without a physicians order for DNR, or without documented wishes to withhold CPR, EMS 911 must be called, the attending physician notified, and emergency basic life support CPR must begin. On [DATE] at 3:46 p.m. an interview was conducted with Staff L, RN. She said there was a system in here, (she pointed to the computer screen) where staff check the physicians orders, and see the code status. If its not there, you go and get the chart. Its supposed be there. The moment the resident comes in for admission, they have to find out if it's yes or no (for CPR). On [DATE] at 3:50 p.m. an interview was conducted with Staff C, LPN. She said the code status is on the computer. Staff C, LPN said when you go in to the resident's name, it is listed right here (pointed to 'code status' on the ribbon beneath a resident's name), and if it's not there, you have to go into the chart. Staff C, LPN verified she was referring to the paper record. Staff C, LPN said, If there's a yellow DNR in the chart, then the resident is a DNR. If not, they're a full code. Staff C, LPN said there is a policy that a status is printed out and put in the chart under advance directives, that says whether the resident is a DNR or full code. She pulled up Resident #80 on the computer and said, she doesn't have a code status. No code status on her. She said she would have to log out and go back in to see physicians orders. She logged out, then logged back in to the orders. Staff C, LPN said, Here it says Resident #80 is a full code. Staff C, LPN indicated they would have to check that in the chart also. The surveyor pointed to the order on the computer screen Patient is a DNR, and asked what it read. Staff C, LPN said, It says DNR. We would have to check the chart. It looks like they didn't take the order out. One is dated [DATE]th, the full code, and the second one, the DNR, is dated December twenty-seventh. Staff C, LPN said she would go check the chart. Staff C, LPN and the surveyor went to the paper chart behind nurses' station, down the hallway. Staff C, LPN opened the chart and turned to the advance directives tab, and found the yellow DNRO. Staff C, LPN said, It's right here, dated December twenty-third. The page in front of the yellow Florida DNRO was a physician's order which indicated resident is a full code. Staff C, LPN said, This is the old one, dated December seventh. Obviously, the updated one is current. So we also need an order to put in the chart. On [DATE] at 4:01 p.m. in an interview with Staff D, RN, she said, We look in the system to see the code status. If we find that it is not in the system, we go to the chart and see if the code status is in the chart. We are looking for the advance directives. It is supposed to have the status if it isn't in the system. We make sure we are dealing with the right chart, the right patient. Open it up to advanced directives and look for the code status. When we have a new admission, if the patient (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105591 If continuation sheet Page 5 of 14 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 105591 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/16/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Tampa 3612 E 138th Ave Tampa, FL 33613 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few is alert, two nurses go in to verify whether the patient wants to be resuscitated or not. Then we call the doctor and let him know. Then we write an order and put it in the system. We have to write a note describing what the patient wants. Then we call the doctor and put it in the system. On [DATE] at 4:08 p.m. an interview was conducted with Staff E, RN. Staff E, RN said she can pull it up on the computer. If it's not there, she can pull the chart. The code status is under the photo on the computer. Staff E, RN said it is also under physician's orders. She can look at the orders in the computer, or she can look in the chart. There is a DNR or advance directive in the chart. Two nurses go in and ask the patient what their wishes are. We call the doctor and tell them what the patient wants. We put a progress note in; both nurses, that says what the patients wishes are. We put it in the orders in the computer. We also print out the phone order and put it in the chart. On [DATE] at 4:17 p.m. an interview was conducted with the ADCS (assistant director of clinical services). The ADCS said, Usually we have two nurses that go in. If the resident is alert and oriented, and they don't have a surrogate, then we explain what the advance directive is; the code status. They have to be alert and oriented. Then you call the physician and tell them their wishes are full code or DNR, and obtain a telephone order. Then, they come in a sign the paper for DNR process. It's entered into PCC (the electronic medical record) and a copy goes into the chart. The nurses check the orders. They can start in PCC. The chart is always available. You want to grab that chart and verify. It has happened. We had a resident who was full code one day, and was DNR the next day. We pull the orders as they change, and we actually verify them with another nurse. We remove all those orders from the chart if they changed their resuscitative status. The surveyor asked if there was an order for full code and DNR how the nurse would determine which one was correct. The ADCS said, I would check the date and time. Normally it would go with the last order. I would call the physician and family and verify the order. On [DATE] at 4:28 p.m. an interview was conducted with the DON (Director of Nursing). She said, The patient comes in with a yellow sheet. That would be a DNR depending on who signed it. Two nurses will go in and verify that the patient wants to be a DNR. They will write a note, stating they witnessed it, call the physician and get the order. Put the order under the advanced directives tab. They put a copy in the physician's book so they can sign it. Physicians come in once a week, twice a week. If the patient is critical we will fax it to the physician. There is no actual timeframe. They will look in the EMAR (electronic medication administration record). It will say the code status on the EMAR and the orders. If there's nothing under the orders, then they will go to the chart, the hard copy on the rack. Normally we bring that to a code anyway. They are going to go under advanced directives to see if there's an order for it. If there is nothing there, they will initiate CPR. They can look at the latest progress note also. It would be the last date on there. If the full code was 1/1 and the order on 1/2 is DNR, it would be a DNR. It would be the last date. The surveyor informed her the first page under the advanced directives tab in Resident #80's chart contained an order indicating Resident #80 was a full code. The DON said, I would have to look at the chart and see how it was placed in there. We would look at the last date. The DON said best practice is to remove the full code when they enter the DNR. 2. Record review of the admission Record for Resident #89 revealed the Resident was admitted on [DATE] from an acute care hospital. During an observation on [DATE] at 11:25 a.m. with Resident #89 and her son, who was her designated Power of Attorney (POA), the SSD (Social Services Director) entered the resident's room. She provided Resident #89 a goldenrod Florida Do Not Resuscitate Order (DNRO). Resident #89 signed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105591 If continuation sheet Page 6 of 14 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 105591 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/16/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Tampa 3612 E 138th Ave Tampa, FL 33613 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 0578 document. Level of Harm - Minimal harm or potential for actual harm An interview was conducted on [DATE] at 1:05 p.m. with Resident #89 and her DPOA. Resident #89 said she desired to have a DNR order. Residents Affected - Few Phone interview with POA on [DATE] at 4:07 p.m. revealed that the POA will sign the Resident's name if needed and they will write POA next to the signature. Record review of the Advance Directives- Code Status Quick View Guide, revealed the following: 1) Two Nurses will witness and document physician's order for DNR: Resident/Designated Health Care Decision Maker will sign the yellow Florida DNR form (this form is for transport communication for EMT's, Medics and ER staff only). Health Care Decision Maker may sign in person, via fax or scanned in email. Form will be faxed to physician for signature by Social Services. Copy of DNR order in hard chart in the Advanced Directives section. 2) The Code Status order entered in to PCC (Point Click Care) is the primary source for validating a resident's code status. In the event a resident becomes unresponsive and without pulse or respirations. Check the Order in PCC. Record review of physician orders in the electronic medical record revealed an active CPR; full code status, dated [DATE] and an active DNR status dated [DATE]. Record review of Progress Notes, dated [DATE], revealed, Resident alert and oriented able to make needs know. This nurse along with another nurse witness addressed code status. Resident states she wishes to be DNR. Son (POA) confirmed. MD will be called for order. This nurse along with another nurse called MD to obtain orders for resident to be DNR. Doctor gave orders. Record review of Partners in Care Meeting, dated [DATE], revealed, code status verified- son at bedside, Resident wants DNR status. *Photographic evidence was obtained. Record review of Progress Notes, dated [DATE] at 10:37 a.m., revealed, two nurses addressed DNR code status on 12-30-19 she wants to be a DNR. Asked resident to sign on 12-30-19. She states she cannot, readdressed the situation today but she, again, says, yes, she wants to be DNR but we have to wait for son to come in this afternoon so she can attempt to sign the DNR. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105591 If continuation sheet Page 7 of 14 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 105591 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/16/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Tampa 3612 E 138th Ave Tampa, FL 33613 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure residents with pressure wounds received care and treatment to promote healing, prevent infection and prevent new wounds from developing for one resident (#7) of two sampled residents. Residents Affected - Few Findings Included: During observation of wound care for Resident #7, on 1/16/2020 at 9:36 a.m., the ARNP was present during the observation and staff member I, LPN removing bleach wipes with bare hands and placing a bleach wipe into each cup times two. One large ampoule of normal saline, three - 4 x 4 gauze pads, one pad of skin prep, scissors and one wound vac kit. Staff member I, LPN cleaned off the bedside table using a bleach wipe with her bare hand while keeping her barrier with supplies in her left hand then placed the supplies on the table. After placing the barrier and supplies on the bedside table the staff member went to wash her hands. Resident #7 was lying on his back on an air mattress. Staff member I, LPN was asked if she would obtain assistance with the dressing change. Staff member I, LPN stated she usually completes it herself since the aides are busy. Resident #7 was lying on a chux pad with the brief opened. Staff member I, LPN, donned gloves and removed the odorous dressing and discarded the tubing and dressing in the clear plastic trash bag. The ARNP asked Staff member I, LPN if she was going to get assistance with the wound care. Staff member I, LPN stated the aides were busy. Staff member I, LPN used the same gloves to clean the circular wound with normal saline using her left hand to hold the resident toward his side and the right hand to clean the wound x 2. The resident was laid on his back with the chux pad under the cleaned wound. Staff member I, LPN cut the sponge with the same gloves and barely lifted the resident's left side off the bed and applied the sponge to the wound and laid the resident back onto the chux pad to pick up the tape, applied the tape, then the suction tubing and turned on the wound vac to 125 psi with the same gloves used to clean the wound. Staff member I, LPN then doffed gloves and added one new glove to wipe scissors at the bedside, doffed the glove then washed her hands and walked in to the hallway. Staff member I, LPN then picked up the trash, scissors and tied the trash and shoved the clear plastic bag into the right side of the treatment cart. Staff member I, LPN then used a bleach wipe without gloves to clean the scissors. She used her right hand to throw the dirty wipe into the trash and used the mouse with the right hand to document on the computer. Staff member I, LPN confirmed, directly after the observation, she did not perform hand hygiene, change gloves between clean and dirty and laid the resident back down on the chux pad after cleaning the wound. The nurse stated she did not always wear gloves using the bleach wipes. Review of the physician orders reflected to clean the left buttocks with normal saline, skin prep periwound, apply wound vac every Tuesday, Thursday and Saturday and as needed at 125 PSI every day shift for pressure wound dated 12/10/19. Review of the facility matrix reflected a stage IV in house acquired wound. Review of the wound care progress notes dated 1/7/20 reflected a resident with a wound of left buttock measuring 2 x 1.9 x 1.3 cm with inflammatory stage and unable to progress to healing stage due to presence of a biofilm. No change in wound care. Review of the wound specialist progress notes dated 12/31/19 reflected the wound on the left buttock measured 2 x 1.9 x 1.3 cm with 10% muscle, 80% granulation tissue and 10% slough. The wound was in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105591 If continuation sheet Page 8 of 14 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 105591 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/16/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Tampa 3612 E 138th Ave Tampa, FL 33613 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 0686 Level of Harm - Minimal harm or potential for actual harm an inflammatory stage and unable to progress to a healing phase because of the presence of biofilm. Pertinent medications Zosyn IV 4.5 gram three times a day. Review of the care plan reflected Resident # 7 required extensive to total assist to complete activities of daily living. Residents Affected - Few Focus area for skin breakdown as the resident is frequently incontinent. Inconsistent with toileting needs and requires assistance with mobility. On 5/29/19 a wound opened to the left gluteal fold requiring antibiotics, on 7/20/19, for a wound infection, 7/30/19 referred to wound clinic, 8/16/19 antibiotics for a wound infection, 9/5/19 to 9/11/19 hospital stay, 11/7/19 antibiotics for wound infection. Interventions included encourage and assist to reposition, dated 4/16/19, monitor skin during care assistance, dated 4/16/19, and wound vac as ordered, dated 9/13/19. Review of the Minimum Data Set (MDS) reflected the resident's brief interview for mental status (BIMS) of 7 meaning severe cognitive impact, dated 11/20/19. Section G bed mobility reflected total assistance of two plus persons. During an interview, on 1/16/20, at 12:12 p.m. with Director of Nursing (DON) she confirmed the staff should be performing hand hygiene prior to donning or doffing gloves and after cleaning a wound. Review of the policy and procedure for hand hygiene, revised on 8/19, 2 pages reflected: the purpose of this procedure is to provide guidelines to employees for proper and appropriate hand hygiene techniques that will aid in the prevention of transmission of infections. 7. After contact with blood, body fluids, secretions, excretions, mucous membranes or broken skin. Review of the policy and procedure for wound care, effective date of 10/14, 3 pages reflected: 12. Position resident. Place disposable cloth next to resident (under the wound) to serve as a barrier to protect the bed linen and other body sites. 13. Put on exam glove. Loosen tape and remove dressing. 14. Pull glove over dressing and discard into appropriate receptacle. Wash hands. 15. Put on disposable gloves. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105591 If continuation sheet Page 9 of 14 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 105591 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/16/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Tampa 3612 E 138th Ave Tampa, FL 33613 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure one Resident #13 was free from a significant medication error related to medication administration of an insulin flex pen with another resident's name on the label. The facility failed to identify the error and was stopped prior to administration of the insulin for one of one sampled residents receiving insulin. Residents Affected - Few Findings Included: During observation of sliding scale insulin administration on 1/15/20 at 4:22 p.m. with staff member L, RN, she verified the order of Insulin Aspart solution pen-injector 100 unit/ML and stated Resident #13 will receive 2 units of insulin. Staff member L, RN went into the top drawer of the medication cart and looked for the resident's pen by name. She pulled out a pen from the top right side of the drawer and stated she had a lot of residents on insulin. The computer screen was on the page that reflected the sliding scale from 151 to 200. Staff member L, RN looked at the insulin pen which reflected Novolog with a small pharmacy label. The clear plastic bag contained a faded label. Staff member L, RN attached the new needle and dialed in 2 units. Staff member L, RN turned around to walk toward Resident #13 and asked the resident where she would like the injection. The surveyor asked Staff member L, RN to look at the insulin pen to observe the small pharmacy label on the pen to verify the resident's name. The Name on the insulin pen belonged to Resident #48. Staff member L, RN was asked to verify Resident #13's name on the insulin pen and the nurse stated that was the incorrect resident. Staff member L, RN immediately removed the needle on the syringe and verified the plastic bag label also belonged to Resident #48. Staff member L, RN looked through the insulin pens and could not find Resident #13's sliding scale insulin and stated that it must have been finished and walked to the medication room and retrieved a new pen from the refrigerator. Staff member L, RN stated thank you for rechecking the name and confirmed the new pen was labeled on the clear plastic bag and on the Novolog pen Resident #13's name. She attached the new needle and set the dial to 2 units without priming the pen and turned again to Resident #13 and asked her where she would like the injection while walking toward the resident. Resident #13 stated anywhere but the bellybutton while laughing. An interview on 1/15/20 at 5:24 p.m. was conducted with the Risk Manager. She confirmed the insulin error would be considered a near miss and significant error. She confirmed the nurse should be priming the insulin pen prior to using it and had been trained on this process and the five rights prior to administering medications and would start an immediate in service. During a phone interview with the pharmacist on 1/16/20 at 11:37 a.m. she confirmed that anyone receiving insulin should get the right order and the nurse should prime the insulin with 2 units the first time using the pen. During and interview on 1/16/20 at 11:50 a.m. with DON she confirmed the in-service was completed on the use of the insulin pen and priming. The DON confirmed the staff are educated on hire and annually. The DON stated she was not aware the wrong resident almost received the wrong insulin pen and confirmed the nurse should have verified the resident and five rights prior to giving the insulin. The DON stated they do not train on priming the insulin pen from the package insert since they do not receive the manufacturer's instructions from the pharmacy but do receive guidance on insulin products from the pharmacy. Review of the clinical competency for insulin injections was completed for staff member L, RN on 1/16/20 and 12/9/19. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105591 If continuation sheet Page 10 of 14 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 105591 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/16/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Tampa 3612 E 138th Ave Tampa, FL 33613 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 0760 Level of Harm - Minimal harm or potential for actual harm Review of the pharmacy guidance for using insulin products reflected two pages dated 3/2019 in section 3. Preparation of product subsection g. To minimize air bubbles in the pen-like devices prime the pen prior to each and every injection by pushing 2 units in to the air until a drop of insulin is seen at the top of the needle. If this does not happen after 2 to 6 attempts (refer to prescribing information), change needles. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105591 If continuation sheet Page 11 of 14 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 105591 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/16/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Tampa 3612 E 138th Ave Tampa, FL 33613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, record review, policy review, and CDC guidelines, the facility failed to ensure appropriate hand hygiene and glove use was utilized during medication administration for one (#91) of eight residents observed during medication administration, and the facility failed to ensure a nebulizer and bagged mask was kept off the floor for one (#57) of eight residents observed during medication administration, and for touching medications with bare hands during administration, and failing to clean the blood pressure cuff after use, and for failing to clean the blood pressure cuff prior to use for one (#16) of eight residents observed during medication administration, and failure to ensure a urinary catheter was maintained off the floor for one (#44) of two residents reviewed for appropriate catheter care. Residents Affected - Few Findings Included: 1. During Medication observation for Resident #91 on 1/14/20 at 4:06 p.m., staff member J, LPN removed one ampoule of refresh plus on the barrier, then donned a glove to remove one sucralate tab one gram and place into the medication cup, doffed the glove and preceded into Resident #91's room. She placed the barrier on the bedside table and donned gloves without hand hygiene. The LPN applied two drops into the left eye, doffed gloves and washed hands. She donned gloves and placed two eye drops of refresh plus into the right eye. Doffed gloves and washed hands. 2. During medication administration for Resident #57 on 1/15/20 at 9:27 a.m. staff member K, LPN was observed removing a blood pressure cuff from her pocket and using it to obtain the resident's blood pressure of 127/62 with a pulse of 81 then placing the cuff on top of the medication cart in a small bag without cleaning the blood pressure cuff. The nurse stated that she uses her own blood pressure cuff since she has to check blood pressures and the aides are busy when she is ready to dispense blood pressure medications. Staff member K, LPN was observed putting one tramadol 50 mg, one simethicone 80 mg, one colace 100 mg, one xanax 0.25 mg,one mucinex DM, one Verapamil 360 mg tab and one eliquis 2.5 mg tab into a medicine cup. Staff member K, LPN then spilled the medications on to the medication cart and used her left hand to scoop up the medication to place in the med cup and a spoon to place another medication from the medication cart into the medicine cup. Staff member K, LPN was moving quickly and had to be asked to verify the quantity of medication after spilling them on the medication cart. After providing Resident #57 her oral medication she found the nebulizer machine on the floor between Resident #57's chair under the curtain on Resident #16's side and started Resident #57's treatment with the nebulizer on the floor. Staff member K, LPN went to the medication cart and checked off Resident #57's medication and went back in the room to get Resident #16's blood pressure with the same blood pressure cuff that had not been cleaned. During an interview on 1/15/20 at 5:24 p.m. the Risk Manager confirmed the nebulizer and mask should not be on the floor, and the nurse should have cleaned the blood pressure cuff in between use as well as the facility really does not like the staff using personal equipment on the residents. During an interview on 1/16/20 at 12:12 p.m. with the DON, she confirmed gloves should be changed with hand hygiene performed before and after and when using blood pressure cuffs, they should be cleaned in between use. 3. Review of the policy and procedure for hand hygiene revised on 8/19, 2 pages reflected: the purpose of this procedure is to provide guidelines to employees for proper and appropriate hand hygiene techniques that will aid in the prevention of transmission of infections. 4. Before preparing or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105591 If continuation sheet Page 12 of 14 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 105591 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/16/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Tampa 3612 E 138th Ave Tampa, FL 33613 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 handling medications. Level of Harm - Minimal harm or potential for actual harm Review of the cleaning and disinfection of Resident care items and equipment policy revised October 2018, two pages reflected: Resident - care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. 1.c. Non-critical items are those that come in contact with intact skin but not mucous membranes. (1) non-critical resident care items include blood pressure cuffs. Residents Affected - Few 4. Resident #44 was admitted to the facility with diagnoses of obstructive uropathy and urine retention, as reflected by the facesheet in the admission record. A review of the 11/16/19 MDS assessment indicated Resident #44 had an indwelling catheter. Section H, bowel and bladder, also reflected Resident #44 was always incontinent of bowel. Section C, cognition, reflected a BIMS score of 13, indicating Resident #44 was cognitively intact. Section G, functional status revealed Resident #44 required extensive assistance of one person for bed mobility. An observation was conducted on 1/13/20 at 2:44 p.m. Resident #44 was in her bed. The catheter bag was on the resident's right side of the bed hanging from the bed frame. It was resting on the floor in a privacy bag. The urine was yellow and cloudy. On 1/14/20 at 9:30 a.m., an interview was conducted with Resident #44's family member. She said Resident #44 was supposed to be checked for a UTI (urinary tract infection) because she has been a little loopy lately. She also said Resident #44 had been to the hospital in September with a really bad UTI. On 1/15/20 at 4:48 p.m. another observation was conducted. Resident #44 was lying on her back in her bed, with her eyes closed. The catheter bag was on the right side of the bed sitting on the floor. At 4:56 p.m. on 1/15/20 Staff F, LPN confirmed the catheter bag was on the floor. Staff F, LPN put on a pair of gloves, and removed the bag from the floor and placed it on the bed frame. She asked Resident #44 if she had caused it to fall. Resident #44 said she had an X-ray of the hip earlier and it might have gotten knocked off then. A urinary analysis sample dated 1/15/20 showed the sample was cloudy, positive for nitrites, with 1+ bacteria, 21-50 wbcs (white blood cells), and 21-50 rbcs (red blood cells), indicating a UTI was likely. On 1/16/20 at 12:01 p.m. in an interview with the DON, she said the catheter bag had to be maintained off the floor. A review of the policy, Nursing-Catheter Care, including Drainage Bag Care/Maintenance, dated October 2014, reflected the following information: Purpose To provide safe and proper care of the resident with an indwelling urinary catheter (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105591 If continuation sheet Page 13 of 14 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 105591 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/16/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Tampa 3612 E 138th Ave Tampa, FL 33613 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 To minimize the risk of bladder infection Level of Harm - Minimal harm or potential for actual harm To maintain skin integrity Procedure Residents Affected - Few 8. Position the drainage bag below the level of the resident's bladder. Secure to the bed or wheel chair in such a manner that neither the bag nor the spigot touches the floor. coil excess tubing on bed verifying that there are no obstructions or kinks in tubing. The following information was found on the CDC (Centers for Disease Control) website at https://wonder.cdc.gov/hai/pdfs/cautiguideline2009final.pdf: 111. Proper Techniques for Urinary Catheter Maintenance 2. Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105591 If continuation sheet Page 14 of 14