Inspection·September 23, 2021

F 0554 shortened expiration date once opened or opened. Level of Harm - Minimal harm or potential for actual harm - When ophthalmic solutions and suspensions are opened the bottle should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened bottle. Residents Affected - Few - Bedside Medication Storage: Facility should not administer/provide bedside mediations or biological's without a Physician/Prescriber order and approval by the Interdisciplinary Care Team and Facility administration. Facility should store bedside medications or biological's in a locked compartment within the resident's room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105591 If continuation sheet Page 2 of 29 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 09/23/2021 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 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview with the resident, interview with facility staff, and review of facility documents, the facility failed to provide one resident with impaired vision, (Resident #56) with assistance at meals, leisure activities to meet his needs of a total sample of 21 residents reviewed for accommodation of needs. Residents Affected - Few Findings included: A review of the admission Record for Resident #56 showed the resident was admitted to the facility on [DATE] with diagnoses that included gastrointestinal hemorrhage, a wedge compression fracture of the spine, macular degeneration and glaucoma. On 09/20/21 beginning at 11:52 a.m. Resident #56 was observed sitting in his wheelchair next to his bed with the over bed table in front of him. His television was on. When the surveyor knocked on his door and called out to him, the resident looked at the door, toward the sound, but it didn't appear that he was looking at the surveyor. The resident was observed to be holding his call bell and to the cord to the receiver of the phone tightly. When asked why, he reported that he had to hold on to them as that was the only way he could contact anyone. He reported that when anyone came in to do anything for him, they would never leave the call bell or the phone in the same place, and then he couldn't find them. He confirmed he was vision impaired and he confirmed that he usually had to tell staff he could not see well. The resident was not wearing glasses during the interview. At lunch on 09/20/2021, at approximately 12:50 p.m., the resident was observed in his room, in his wheelchair next to his bed with his lunch tray on his table in front of him. He was observed to be alone in the room. He was observed without his glasses on. When asked if he had been told what he was served, he said no, he had to taste what was on his plate to know. During the interview the resident was holding a cup of ice cream in one hand and a straw in the other. He was poking the ice cream and then sucking the melted bits of ice cream through the straw. He had been served a chopped salmon burger with soft mixed vegetables and sweet potato fries. By the end of the meal he had eaten about half of the meal. On 09/21/2021 at approximately 8:30 a.m., Resident #56 was observed sitting up in bed, with his over the bed table across his waist and his breakfast tray on the table. He had both a fork and a spoon in his bowl of oatmeal, but was using the fork to eat the oatmeal. On 09/22/2021 at 12:45 p.m. the resident was observed to be sitting in his wheelchair at a table in the day room. His lunch tray was on the table in front of him. He was holding an ice cream cup but did not have a spoon. His bag of silverware was unopened, on his tray, with the open end pointing away from him. When asked if he was going to eat, he replied that it might be difficult for him to do that with his vision difficulty. When asked if anyone had told him what he was having, he said no and asked if the surveyor would. He asked for his meat to be cut up and a facility nurse was stopped in the hall and asked to assist. During all of the observations and interviews with the resident, he had not been wearing glasses and there were no glasses observed on his over bed table or side table. During the observations and interviews with the resident while he was in his room, the television was on. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105591 If continuation sheet Page 3 of 29 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 09/23/2021 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 0558 Level of Harm - Minimal harm or potential for actual harm On 09/23/2021 at 8:55 a.m., Staff S, Life Enrichment Aide was delivering the Daily Chronicle (detailing activities for the day at the facility), which the resident received. When asked if he was satisfied with listening to the television, he confirmed yes he liked the news. When asked if he was interested in any puzzles or books, Resident #54 reported no, explaining he had impaired vision. He confirmed that he was not able to read the Daily Chronicle. Residents Affected - Few A review of the physician's note, dated 08/13/2021, included in the assessment, blindness. A review was conducted of the Minimum Data Set (MDS) admission assessment dated [DATE]. Section B for Hearing, Speech and Vision identified Resident #56's vision as adequate with corrective lenses. His Brief Interview for Mental Status score was coded as a 10, indicating his cognition was moderately impaired. His diagnoses of cataracts, glaucoma, or macular degeneration was identified. An interview was conducted with the Staff M, Licensed Practical Nurse (LPN)/MDS on 09/23/2021 at 3:00 p.m. to confirm the above information about Resident #56. She agreed to visit Resident #56 to observe and speak with him about his vision. At 3:50 p.m. after an interview with the resident, Staff M reported the resident confirmed he had glasses, but didn't know where they were. She reported the resident confirmed that even with his glasses, his vision was still impaired. On 08/04/2021 a Life Enrichment Evaluation was conducted with Resident #56. It identified the resident as having adequate vision, being oriented x 3, and preferring to spend his free time in his room with leisure activities conducted in the afternoon. Activities that were very important to him included clothing/fashion, sports, music, television, conversation, snacking, keeping up with the news and family or visitors. A note written by Life Enrichment staff dated 08/04/2021 indicated he enjoyed doing crossword puzzles and he enjoyed being outside. A nutrition assessment, dated 08/05/2021, by the Registered Dietitian (RD) was reviewed, which documented the resident's height as 65 and his weight as 130 lbs (pounds). The assessment identified his intake at meals as good. The RD referenced intake records which documented his intake at more than 50% of most meals. However, due to his increased needs, recommendations had been made for fortified foods at meals, and vitamin, mineral and protein supplements. Within one month, according to the RD's follow up note dated 09/03/2021, the resident's weight had dropped to 122 lbs, a loss of 6.2% in one month. An interview was conducted with the Staff L, LPN/nurse supervisor on 09/232021 beginning at 12:30 p.m. She agreed to visit Resident #56 with the surveyor, but commented that she didn't know him very well. Staff L asked the resident about his vision and the resident replied that it had deteriorated since he had been in the facility. The resident denied having glaucoma but confirmed he had macular degeneration. In an interview with his aide, Staff N, Certified Nursing Assistant (CNA), on 09/23/2021 beginning at 5:00 p.m., she confirmed that she usually worked on Resident #56's hall on both the day and evening shifts. She reported that she was aware he had impaired vision, but staff tried to maintain his independence by telling him where his food was on his plate and where his drinks and dessert were located. She said that she never saw him wear glasses. She said the manager just told the staff that his glasses were missing, and she looked in all of his drawers and even the pockets in all of his clothes for them, but did not find them. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105591 If continuation sheet Page 4 of 29 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 09/23/2021 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and facility staff interviews, and review of facility documents, the facility failed to revise a care plan to meet the needs related to accommodating needs, specifically for impaired vision for one resident (#56) of 21 residents reviewed. Findings included: Review of the admission Record for Resident #56 showed the resident was admitted to the facility on [DATE] with diagnoses that included gastrointestinal hemorrhage, a wedge compression fracture of the spine, macular degeneration and glaucoma. On 09/20/21 beginning at 11:52 a.m. Resident #56 was observed sitting in his wheelchair next to his bed with the over bed table in front of him. His television was on. When the surveyor knocked on his door and called out to him, the resident looked at the door, toward the sound, but it didn't appear that he was looking at the surveyor. The resident was observed to be holding his call bell and to the cord to the receiver of the phone tightly. When asked why, he reported that he had to hold on to them as that was the only way he could contact anyone. He reported that when anyone came in to do anything for him, they would never leave the call bell or the phone in the same place, and then he couldn't find them. He confirmed he was vision impaired and he confirmed that he usually had to tell staff he could not see well. The resident was not wearing glasses during the interview. At lunch on 09/20/2021, at approximately 12:50 p.m., the resident was observed in his room, in his wheelchair next to his bed with his lunch tray on his table in front of him. He was observed to be alone in the room. He was observed without his glasses on. When asked if he had been told what he was served, he said no, he had to taste what was on his plate to know. During the interview the resident was holding a cup of ice cream in one hand and a straw in the other. He was poking the ice cream and then sucking the melted bits of ice cream through the straw. He had been served a chopped salmon burger with soft mixed vegetables and sweet potato fries. By the end of the meal he had eaten about half of the meal. On 09/23/2021 during a visit with the resident, beginning at 8:55 a.m., Staff S, Life Enrichment Staff was observed delivering the Daily Chronicle (detailing activities for the day in the facility) to the residents. She agreed to step into the resident's room and talk with the surveyor and the resident. She reported that she knew him a little from delivering the chronicle. She asked him if he wanted any activities - something to do? He agreed the television was enough but he would like some music also. She asked if he wanted the TV on now and he agreed and asked for a specific news channel. I asked the resident if he wanted puzzles, referring to the Life Enrichment care plan. Resident #54 reported no, explaining he had impaired vision. He confirmed that he was not able to read the Daily Chronicle. Care plans were developed based on the Minimum Data Set (MDS) assessment dated [DATE]. The resident was identified as having adequate vision when wearing corrective lenses. The care plan, initiated on 8/4/21 and revised on 8/10/21, referred to the diagnoses of Glaucoma and Macular Degeneration. Interventions included orienting him to his surroundings as necessary and placing items in easy reach and orienting him to their placement. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105591 If continuation sheet Page 5 of 29 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 09/23/2021 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A care plan was developed for the resident's risk for falls, initiated on 8/4/21 and revised on 8/30/21, related to his poor vision. Interventions included placing items used in easy reach, such as his water, telephone and his call light. The resident was assessed by activity staff, which was reflected in a care plan, initiated on 8/10/21, as being independent in his decision making regarding his leisure time. It was documented that he preferred to engage in independent activity in his room daily, by watching television, and doing word puzzles. An interview was conducted with the Staff L, LPN/nurse supervisor on 09/23/2021 beginning at 12:30 p.m. She agreed to visit Resident #56 with the surveyor but commented that she didn't know him very well. Staff L asked the resident about his vision and the resident replied that it had deteriorated since he had been in the facility. The resident denied having glaucoma but confirmed he had macular degeneration. An interview was conducted with the Staff M, Licensed Practical Nurse (LPN)/MDS on 09/23/2021 at 3:00 p.m. to confirm the above information about Resident #56. She agreed to visit Resident #56 to observe and speak with him about his vision. At 3:50 p.m. after an interview with the resident, Staff M reported the resident confirmed he had glasses, but didn't know where they were. She reported the resident confirmed that even with his glasses, his vision was still impaired. She agreed the assessment did not fully capture Resident 56's status related to his impaired vision and increased needs. In an interview with his aide, Staff N, Certified Nursing Assistant (CNA), on 09/23/2021 beginning at 5:00 p.m., she confirmed that she usually worked on Resident #56's hall on both the day and evening shifts. She reported that she was aware he had impaired vision, but staff tried to maintain his independence by telling him where his food was on his plate and where his drinks and dessert were located. She said that she never saw him wear glasses. She said the manager just told the staff that his glasses were missing, and she looked in all of his drawers and even the pockets in all of his clothes for them but did not find them. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105591 If continuation sheet Page 6 of 29 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 09/23/2021 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review the facility failed to ensure treatment and care was provided related to the appropriate application of a splint for one resident (#81) of 48 sampled residents. Findings included: Review of Resident #81's admission Record revealed this resident was admitted to the facility on [DATE] with a diagnosis primary diagnosis of Infection and inflammatory reaction due to internal right hip prosthesis. A review of the Minimum Data Set Assessment, dated 6/28/21, indicated Resident #81 had a Brief Interview of Mental Status score of 15 indicating the resident was cognitively intact. Review of the physician orders for September 2021 revealed, Patient to wear right ankle brace in bed as tolerated every day and night shift, with a start date of 7/15/21. Review of the electronic Therapy Page revealed Precautions: (PT) [patient] Fall risk, R [right] THA [total hip arthroplasty] revision (6/15/21), RLE (right lower extremity) WBAT [weight bearing as tolerated], brace for RLE while in bed to maintain neutral hip position. Review of the care plan, dated 6/22/21, revealed that Resident #81 required extensive to total assistance to complete his self-care tasks, due to the diagnosis of osteomyelitis. Interventions included: Patient to wear right ankle brace in bed, as tolerated. Review of the paper chart revealed: Splint/positioning instructions: When in bed 8-10 hrs (hours) as tolerated. This document indicated the following: -Make sure R (right) leg is in normal position when placing on the patient. -Make sure kick stand is visible to maintain R leg in neutral position. -Complete daily skin checks for redness or breakdown. Continued review of this document revealed that on the reverse side of the document were three pictures showing the correct positioning of the splint. The document indicated that it was completed by Staff K, Physical Therapist (PT). Observations on 9/20/21 at 1:27 p.m. of Resident #81 revealed the resident lying in his bed with his eyes closed. A foot splint was noted to be laying on top of the air conditioning unit located under the window next to his bed. Observations on 9/21/21 at 11:38 a.m. of the resident lying in bed revealed he had a boot on his right foot. Interview with the resident at this time, revealed the boot was supposed to help keep his toes point straight up to the ceiling but that it is not on right and something is wrong. He (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105591 If continuation sheet Page 7 of 29 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 09/23/2021 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reported that staff put on the boot each morning after providing care. Closer observation of the resident's foot revealed the boot was in place and the foot was resting on a pillow and leaning sideways to his right side with toes pointing to the window. Observation on 9/22/21 at 11:06 a.m. revealed the resident lying flat on his back in bed asleep, with both of his feet exposed. The resident's right foot was noted to be lying flat on its right side and the foot splint was noted to be laying on top of the air conditioning unit located under the window next to his bed. On 9/22/21 at 12:25 p.m. an observation of Resident #81 revealed the resident was seated up in bed with his midday meal tray. Continued observation of the resident at this time revealed that his right foot was lying flat on its right side, pointed towards the window next to his bed and no splint in place. Observation of Resident #81 on 9/22/21 at 1:35 p.m. revealed him lying on his back in bed with his right foot lying flat on the right side pointing towards the window and no splint in place. Observation of Resident #81 on 9/22/21 at 3:44 p.m. revealed the resident lying on his back in his bed, with his right foot noted to be lying flat and pointing to the right side towards the window. On 9/22/21 at 3:54 p.m. a review was conducted of the Treatment Administration Record (TAR) for the month of September 2021. Staff were to document the application of the right foot brace on days and at night. Closer observation of the TAR revealed that a check mark was in place for the days on 9/22/21. An interview on 9/23/21 at 2:01 p.m. with Staff W, Physical Therapy Assistant (PTA), revealed the resident was currently on caseload for strengthening. He reported that he put the splint on this morning, and the resident will let staff know when he wants it off. He reported the resident will refuse to have the splint on at times. Staff W reported the resident was on a splint program for his right hip, as tolerated. He reported that both staff and the resident had been educated on the use of the splint and the importance of using the kick stand to keep the resident's leg and hip aligned. An interview on 9/23/21 at 2:15 p.m. with Staff X, Registered Nurse (RN) revealed that she was currently assigned to Resident #81 did not know much about him. She reported she was unaware the resident had a splint or when/how the splint was to be used. She reported at this time she had not signed off for any splint use. An interview on 9/23/21 at 2:20 p.m. with Staff Y, Certified Nursing Assistant (CNA) revealed she was currently assigned to this resident and that she was very familiar with him. She reported he does use a foot splint and that she takes it off when he requests and that she just took it off. Staff Y was asked to demonstrate how the splint goes on without putting it on the resident. She demonstrated how the foot splint goes on and how it closes using the attached [hook and loop fastener]. When asked about the stand on the back of the boot she responded, Oh that is nothing, I don't know what it is there for. When asked if there was any direction that staff are to follow to make sure that the boot was on correctly, she responded, No. An interview on 9/23/21 at 2:30 p.m. with Staff K, Physical Therapist (PT) revealed the resident was on PT caseload and currently has a foot brace for his right foot to be on as tolerated when in bed. She reported that staff are to use the kickstand to enable the foot to stay straight up which (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105591 If continuation sheet Page 8 of 29 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 09/23/2021 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 0688 helps to align the resident's hip. Level of Harm - Minimal harm or potential for actual harm Observation was conducted on 9/23/21 at 2:58 p.m. of Staff Y, CNA, with the permission of the resident. Staff Y applied the splint to the resident's right foot. The staff put the boot on but did not utilize the kick stand and left the foot leaning to the right side. At this time Resident #81 intervened and was able to explain to the CNA how to place the splint and utilize the kick stand. The PT also intervened and provided further direction to the CNA to ensure the boot was on correctly utilizing the kick stand. Residents Affected - Few During an interview with the PT at this time she reported the therapy department in-services staff on the application and use of splints, however with the constant turn-over and change in staff they are unable to train every person who may come in contact with the resident as there was no consistency in staff. A request was made for the facility policy on splint use, but not provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105591 If continuation sheet Page 9 of 29 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 09/23/2021 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observation of the resident (#140) at meals, and review of the resident's medical record and facility documents, the facility failed to ensure one (#140) of one resident reviewed for dialysis services received care and services to meet her needs. Residents Affected - Few Findings included: On 09/20/2021 at 1:55 p.m., an interview was conducted with Resident #140. She was sitting in a recliner in her room with the television on. She confirmed that she went to her dialysis sessions three times a week, leaving the facility about 10:30 a.m. and returning by 4:30 p.m. She confirmed she had a catheter in her upper left chest which the facility nurses did not touch at all, she was knowledgeable about her diet and fluid intake, she knew her weight had remained pretty stable and she reported that the dialysis facility drew her labs. She confirmed that she was given a lunch to take with her but since she slept the whole day, she hadn't been eating the packed lunch. She said that since she ate breakfast before she left the facility and had dinner shortly after she returned from dialysis, not eating the lunch had worked out for her. On 09/22/2021 at 10:35 a.m. the resident was observed in her bed with her breakfast tray on her over bed table across her waist. She was sitting up in bed and the television was on. She reported that she had eaten two bowls of oatmeal, half of a slice of toast with jelly and had drank coffee. An unopened 8 ounce carton of milk was also on the breakfast tray but she said she didn't drink milk as it caused her distress. She said she would have liked to have received protein at the meal as she had been told by her doctor at dialysis the day before that her protein was low and she needed to eat more protein. The admission Record showed the resident had been admitted to the facility on [DATE] with diagnoses that included dependence on renal dialysis. A review was conducted of the resident's medical record which revealed communication forms from the resident's dialysis center for two of the three days that the resident had received dialysis and then returned to the facility. The Registered Dietitian (RD) completed a nutrition assessment of the resident on 09/16/2021 which documented the resident's height, weight and Body Mass Index (65, 196 lbs. [pounds] or 89 kg [kilograms], 34.3). The resident's diet order was for a Renal diet with thin liquids. Diagnoses were documented as hypertension, cerebral vascular accident, and diabetes. Her blood glucose values had been normal, her skin was intact and she had limited activity. The RD had determined she had increased needs for protein due to the renal failure with dialysis. She documented that she had educated the resident on consuming an adequate intake of protein due to the dialysis expenditure. The RD's plan was to communicate with the Dietitian at the dialysis center to help manage the resident's dietary needs, which would include obtaining the resident's weights from the dialysis center for the most accurate weight trend. There were no labs referred to in the nutrition assessment, no indication an attempt had been made to contact the dialysis dietitian and no reference to the communication forms from the dialysis center. Two dialysis communication forms were located in the resident's medical record, which the Nurse Manager indicated was where the communication forms were filed. The two forms were dated 09/16/21 and 09/18/2021. Both communication forms documented blood pressure that was high. The resident's pre weights were 106.7 kg and 106.1 kg respectively and post weights were 103 kg and 103.9 kg. These (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105591 If continuation sheet Page 10 of 29 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 09/23/2021 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete documented weights were very different from the weight that was documented for the resident at admission, which was 196 lbs. or 89 kg. The dialysis center was weighing the resident pre dialysis at 235 lbs. and post dialysis at 228 lbs. On 09/22/2021 at 10:30 a.m. the RD confirmed that she had seen and assessed Resident #140. She confirmed that she had not seen any labs in the chart and when she asked the resident when she had her labs drawn at the dialysis facility, the resident reported that she did not know. She confirmed the facility sent a lunch with her and she assumed the resident ate the lunch. The observation that was made of the resident's breakfast on 09/22/2021 was discussed with the RD. The RD reported the resident had requested the two bowls of hot cereal and had reported that she didn't eat eggs. She reported the resident liked milk on cold cereal but then had to admit the resident had not requested cold cereal. The RD provided the resident's documented food preferences which included the dislike of eggs, but there was nothing about the distress the resident felt when she drank milk. The RD confirmed that even though part of the plan was to increase protein in the resident's meals, that had not occurred. The RD confirmed that she had not contacted the Dialysis Center to obtain the resident's dry weight or recent lab reports. Event ID: Facility ID: 105591 If continuation sheet Page 11 of 29 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 09/23/2021 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 09/21/2021 beginning at 2:45 p.m., an observation began of the 100 wing for sufficient staff. Initially only two aides were observed, both in and near to the day room. One aide was providing one on one care to a male resident and the second was talking with that aide. No other aides were observed on the unit. At 2:49 p.m. while walking the halls to observe for the aides, at the end of the high numbered rooms, a resident called out for help. When the surveyors approached the resident she asked for help, that she was wet and needed to be changed. The surveyors asked her to put her call bell on and someone would come to assist. The surveyors walked up the hall, continuing to look for aides and finally when they reached the nursing station without observing any aides, they asked they nurses where their staff were. One of the three nurses at the station reported that they were down the halls. The nurse walked down the low numbered hall and found no aide. She walked down the middle hall and found one aide in the last room providing care. And when she walked down the third hall, where the resident had turned on her light, she found one other aide providing care. Further observation revealed both aides were providing care by themselves to the residents and the two aides were from the Day Shift. By then it was 3:00 p.m. and upon returning to the nurses station, the nurse was able to name four aides who were working onto the unit. At 3:15 p.m. the resident's call bell that the Surveyor had been speaking with was answered by the Day shift aide who had been across the hall providing care. On 09/22/2021 at 3:10 p.m. a call light was noted at the end of the middle hall on the 100 wing. The surveyor asked the resident if she needed help and the resident reported that she needed her diaper changed adding would you do it for me? The surveyor explained that she would get someone to help her. As the surveyor walked back up the hall to the nurses station an aide (Aide R) passed her on the way to the resident's room. The surveyor watched the aide go into the room and within one minute left the room having turned off the light. The aide walked up the hall and entered a room where another aide was providing care to the resident. The surveyor saw that aide leave that room and continue toward the nursing station and turn to walk down the low numbered hall. The surveyor saw the aide enter the room, speak with another aide and then leave the hall. The aide then left the wing. It was 3:20 p.m. by then. The DON had walked down the hall toward the room where the light had been on but stopped to talk with another resident who was in the hall. The resident at the end of the hall who had turned her light on put her light on again. The DON had not turned around to see the light and walked away from the light toward the nursing station. The surveyor joined the DON half way down the hall and asked her to answer the light with the surveyor. The resident asked the DON the same question and the DON agreed to find someone to help. While walking back to the nursing station the surveyor reported what she had seen take place with the aide who had turned off the resident's light, visited with other aides then left the floor. In an interview with the Director of Nurses on 09/22/2021 beginning at 3:30 p.m. , when asked why the evening shift started at 2:45 p.m. and the day shift ended at 3:15 p.m. she replied that there was a purpose in that. When asked to elaborate on the purpose, she explained that there was a 30 minute overlap of the staff so they could endorse any relevant information for each resident to the oncoming staff. She explained that the aides should be conducting walking rounds to observe residents and let the oncoming shift know of any changes in the status of each resident. On both 09/21/21 and 09/22/21 from 2:45 p.m. until 3:15 p.m., endorsing resident care information from one shift to the other was not observed by two surveyors on the A wing. On 09/21/2021 at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105591 If continuation sheet Page 12 of 29 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 09/23/2021 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 0725 Level of Harm - Minimal harm or potential for actual harm approximately 3:00 p.m. only two aides were observed near to the nursing station and two aides had been identified as providing care to residents in their rooms. On 09/22/2021, at approximately 3:10 p.m. one aide was observed to answer a call light, but turn it off, speak with an aide in a room, find another aide to speak with and then leave the unit. Neither aide was observed to walk down the hall to the resident's room to provide care, until the DON requested that the care be provided. Residents Affected - Few During the interview with the DON on 09/22/2021 which began at 3:30 p.m. , it was noted and a comment made to the DON that the assignment was just being posted on the board in the hall. The DON was asked how aides were to endorse to the oncoming shift, when the assignment was being posted after the Day shift left? The DON reported that the aides have permanent assignments. In an interview with the Aide T who was writing the assignment on the board, on 09/22/2021 at 3:35 p.m., it was revealed that some aides have permanent assignments but with all the agency and call offs, assignments have to change. The Facility Assessment (03/05/2021) was reviewed for their staffing plan related to nurses and aides. (Refer to Section III Facility Resources Needed to Provide Competent Support and Care for Resident Population Every Day and During Emergencies). A chart for Staffing in a 24 hour day listed the Total Number Needed or Average or Range as 18 for Registered and Licensed Nurses. The chart listed 36 for the certified aides. (The chart did not clarify what the number was - whether the number was the total number or average. A note at the end of the section indicated that The Facility adheres to F.S. 400.23 (3) (a) which describes minimum staffing requirements in skilled nursing facilities in the state of Florida.) When this information was compared to numbers listed on the form Calculating Staffing for Long Term Care Facilities, provided for nurse and aide staffing for the period of 08/29/2021 through 09/11/2021, it was noted that the Minimum per shift of licensed nursing hours was only 17, not 18, on every day. There were six days when the total number of aides was below the 36 total number needed or average as listed in the Facility Assessment. Based on observations, record review and interview the facility failed to provide sufficient and competent nursing staff to meet the resident needs according to the care plan and the facility assessment regarding two (#4, #81) of 48 sampled residents, and on 1 of 2 (C-Wing) patient wings related to timely and appropriate response to call light; staff being available for change of shift report on one (100) of two wings and timely administration of medication for two (#90, #58) of five residents observed. Findings included: 1. Interview of a group six of alert and oriented residents who wished to remain anonymous on 9/21/21 at 1:33 PM revealed that staff do not respond timely to the call bell. The residents reported that the call lights will be on and staff are noted to walk past the rooms never responding to the call light. The group reported that if staff do come to the room timely, they will just turn off the call lights, and say they will be back, or say that they are not the resident's CNA or that they are going on break and will get some help, but they never return and no-one else comes. All residents reported that they typically wait for 30 minutes or more for a response for call lights. Continued interview with the group revealed that they knew how long they waited because all of them have a clock on the wall across from their bed. The group reported that sometimes there are no staff around at night and they wonder where everyone went. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105591 If continuation sheet Page 13 of 29 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 09/23/2021 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Observation on 9/22/21 at 11:06 AM of Resident #4's room from the hallway revealed that the call light was illuminating above the room door. Interview with Resident #4 at this time revealed that he was ready to get up so that he would be ready for lunch in the dining room. Continued observation of the call light from the hallway reveled two staff walk by. Observation on 9/22/21 at 11:08 AM, the same 2 staff walk by again and stop and go into room. Staff AA, Certified Nursing Assistant (CNA) noted to turn off the light and could over hear the resident tell her that he was ready to get up. Staff was overheard telling the resident that she will tell his aide, and then she left the room. Review of the assignment posted on the wall indicated that Staff BB, CNA was assigned to Resident #4's room. Observations on 9/22/21 at 11:25 AM while seated at the nursing station with clear view of Resident #4's room revealed that no nursing staff has gone into his room yet. Observations on 9/22/21 at 11:38 AM while seated at the nursing station with clear view of Resident #4's room room revealed that nursing staff had still not gone into his room. Observations on 9/22/21 at 11:47 AM while still seated at the nursing station with clear view of Resident 4's room revealed that no nursing staff have gone into his room to address his needs. Interview with Resident #4 on 9/22/21 at 11:53 AM revealed that he is still waiting to get up for lunch in the dining room, and that he has only seen his aide once before now. While in Resident #4's room on 9/22/21 at 11:55 AM Staff T CNA came into the resident's room to take him to the dining room for lunch and asked the resident why aren't you ready yet, left the room for a moment and came back and said I think his aide went to lunch, but I will get someone to help me get you up. She reported that Resident #4 eats in the dining room and is usually up, dressed and ready for the dining room before 11:30 AM. Interview with the DON on 9/22/21 at 12:09 PM while walking to the resident's room revealed that the expectation is for those residents who go to the dining room and need assistance, to be assisted and ready before lunch. At this time the DON and this surveyor both entered Resident #4's room and the resident explained that he wanted to get up for lunch. At this time meal trays for the resident rooms were being passed and it was noted that none of them were for Resident #4. Review of Resident #4's record revealed that he was admitted to the facility on [DATE] and had diagnoses that include: Non-traumatic intracerebral Hemorrhage; Muscle wasting and atrophy to left forearm, left thigh, left lower leg, left shoulder, left upper arm, and left hand. Review of Resident #4's Annual Minimum Data Set (MDS) dated [DATE] revealed that this resident has a Brief Interview for Mental Status (BIMS) score of 15 (Cognitively intact) and required extensive assistance of one person to complete the tasks of dressing, toilet use, and personal hygiene. 3. Review of Resident #81's record revealed that this resident was admitted to the facility on [DATE] with the primary diagnosis of Infection and inflammatory reaction due to internal right hip prosthesis and has a Brief Interview of Mental Status dated 6/28/21 with a score of 15 (Cognitively intact). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105591 If continuation sheet Page 14 of 29 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 09/23/2021 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observations on 9/20/21 at 1:27 PM of Resident #81 revealed the resident lying in his bed with his eyes closed. A foot splint was noted to be laying on top of the air conditioning unit located under the window next to his bed. Observations on 9/21/21 at 11:38 AM of the resident lying in bed revealed that he had a boot on his right foot. Interview with the resident at this time, revealed that this boot is supposed to help keep his toes pointed straight up to the ceiling but that it is not on right and something is wrong. He reported that staff put on the boot each morning after providing care. Closer observation of the residents foot revealed that the boot was in place and the foot resting on a pillow and leaning sideways to his right side with toes pointing to the window. Observations on 9/22/21 at 11:06 AM revealed the resident lying flat on his back in bed asleep, with both his feet exposed. The residents right foot was noted to be lying flat on its right side and the foot splint was noted to be laying on top of the air conditioning unit located under the window next to his bed. On 9/22/21 at 12:25 PM an observation of Resident #81 revealed him seated up in bed with his midday meal tray. Continued observation of the resident at this time revealed that his right foot was lying flat on its right side, pointed towards the window next to his bed and no splint in place. Observations of Resident #81 on 9/22/21 at 1:35 PM revealed him lying on his back in bed with his right foot lying flat on the right side pointing towards the window and no splint in place. Observations of Resident #81 on 9/22/21 at 3:44 PM revealed the resident lying on his back on his bed, with his right foot noted to be lying flat pointing to the right side towards the window located next to his bed. On 9/22/21 at 3:54 PM a review was conducted of the Treatment Administration Record (TAR) for the month of September 2021. Staff are to document the application of the right foot brace on days and at night. Closer observation of TAR revealed that a check mark was in place for days on 9/22/21. Interview on 9/23/21 at 2:01 PM with Staff W, Physical Therapy Assistant (PTA), revealed that the resident is currently on caseload for strengthening. He reported that he put the splint on this morning, and the resident will let staff know when he wants it off. He reported that the resident will refuse to have the splint on at times. Staff W reported that the resident is on splint program for his right hip, as tolerated. He reported that both Staff and resident have been educated on the use of the splint and the importance of using the kick stand to keep the residents leg and hip aligned. Interview on 9/23/21 at 2:15 PM with Staff X, Registered Nurse (RN) revealed that she is assigned to this resident today and does not know much about him. She reported that she is unaware that the resident has a splint or when/how the splint is to be used. She reported that at this time she has not signed off for any splint use. Interview on 9/23/21 at 2:20 PM with Staff Y, Certified Nursing Assistant (CNA) revealed that she is assigned to this resident today and that she is very familiar with him. She reported that he does use a foot splint and that she takes it off when he requests and that she just took it off. The aide was asked to demonstrate how the splint goes on without putting it on the resident. At this time she demonstrated how the foot splint goes on and how it closes using the attached Velcro. When asked about the stand on the back of the boot she responded oh that is nothing, I don't know what it is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105591 If continuation sheet Page 15 of 29 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 09/23/2021 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few there for. When asked if there is any direction that staff are to follow to make sure that the boot is on correctly she responded No. Interview on 9/23/21 at 2:30 PM with Staff K, Physical Therapist (PT) revealed that the resident is on PT caseload and currently has a foot brace for his right foot to be on as tolerated when in bed. She reported that staff are to use the kickstand to enable the foot to stay straight up which helps to align the resident hip. Observation on 9/23/21 at 2:58 PM of Staff Y, CNA with permission of the resident she applied the splint to the residents right foot. The staff put the boot on but did not utilize the kick stand and left the foot leaning to the right side. At this time Resident #81 intervened and was able to explain to the CNA how to place the splint and utilize the kick stand. The PT also intervened and provided further direction to the CNA to ensure that the boot was on correctly utilizing the kick stand. During an Interview with the PT at this time she reported that the therapy department in-services staff on the application and use of splints, however with the constant turn-over and change in staff they are unable to train every person who may come in contact with the resident as there is no consistency in staff. Review of the paper chart revealed splint/positioning instructions: When in bed 8-10 hrs as tolerated. This document indicated the following: -Make sure R leg is in normal position when placing on the patient. -Make sure kick stand is visible to maintain R leg in neutral position. -Complete daily skin checks for redness or breakdown. Continued review of this document revealed that on the reverse side of he document were 3 pictures showing the correct positioning of the splint. The document indicated that it was completed by Staff K, Physical Therapist (PT) Review of the physician orders revealed Patient to wear right ankle brace in bed as tolerated every day and night shift with a start date of 7/15/21. Review of the electronic Therapy Page revealed Precautions: (PT) Fall risk, R (right) THA (total hip replacement) revision (6/15/21), RLE WBAT (right lower extremity weight bearing as tolerated), brace for RLE while in bed to maintain neutral hip position. Review of the care plan dated 6/22/21 revealed that Resident #81 required extensive to total assistance to complete his self care tasks, due to the diagnosis of osteomyelitis. Interventions include -Patient to wear right ankle brace in bed, as tolerated 5. Staff F, Licensed Practical Nurse (LPN) was observed, on 9/21/21 at 11:31 a.m., dispensing and administering a total of five medications for Resident #90, four of which were to be administered at 9:00 a.m. and did not include one oral medication, Folic Acid, that the staff could not locate. Immediately prior to the observation, Staff I, Registered Nurse (RN) was observed speaking with Staff F (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105591 If continuation sheet Page 16 of 29 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 09/23/2021 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few in the hallway outside of Resident #90's room. Staff I stated she was helping the LPN due to him being backed up. On 9/21/21 at 12:10 p.m., Staff F completed the administration of Resident #90's medications and reported that the reason for late medications was that he had not arrived to the facility until 9:30 a.m., doing them a favor, normally works 3-11 p.m. shift on the other unit (A-wing), that prior to his arrival staff had administered medications to one person on the assignment, and that Staff I had assisted him for one room prior to the observation. A review of the facility floor plan indicated that the hallway which Staff F had been observed contained nine (9) resident rooms and those rooms contained eight (8) residents as of 9/21/21 at 4:14 p.m. On 9/22/21 at 12:09 p.m., Staff Member G, Licensed Practical Nurse (LPN), stated that she was an agency nurse who had started working at the facility last week. She stated medications were late because she received her assignment late. Resident #58 was observed with his lunch tray on an over-the-bed table in front of the resident. Staff G, LPN, was observed dispensing, at 12:31 p.m. on 9/22/21, Resident #58's oral medications. The staff member administered the residents oral medication and residents subcutaneous dose of insulin at 12:57 p.m. on 9/22/21. A review of Resident #58's MAR indicated 15 oral medications, including an inhaler, that Staff G administered which were due at 9:00 a.m., and a subcutaneous injection of Novolog which was due before meals. The policy, Interim Policy for Suspected or Confirmed Coronavirus (COVID-19), effective December 2020 and revised January 2021, indicated that Maintaining appropriate staffing in healthcare facilities is essential to providing a safe work environment for healthcare personnel (HCP) and safe patient care. As the COVID-19 pandemic progresses, staffing shortages will likely occur due to HCP exposures, illness, or need to care for family members at home. The facilities plan and process to mitigate staff shortages for safety and quality of care provided to the residents of the facility included Schedules may be adjusted to meet the needs of the residents and Agency employees will receive adequate orientation, training, and verification of competency. During an interview, at 2:12 p.m. on 9/22/21, the Director of Nursing (DON) confirmed that the facility had a problem with late medications and were going to move schedule medication administration times to a patient-centered liberalized times: day, afternoon, evening and bedtime, but it was going to take 2 months. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105591 If continuation sheet Page 17 of 29 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 09/23/2021 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to ensure target behaviors, side effects, and outcomes were monitored and documented for two (#6 and #30) out of five residents sampled for unnecessary medications. Findings included: 1. On 9/20/21 at 1:05 p.m., Resident #6 was observed lying in bed, quiet and eyes closed. The resident was very thin with muscle-wasting, wearing a nasal cannula delivering 3 liters of oxygen per minute. On 9/21/21 at 8:51 a.m., the resident was observed lying in bed, wearing a nasal cannula delivering oxygen, mouth open, eyes closed, and with neck hyperextension on pillows. Resident #6 was admitted , per the admission Record, on 1/11/21 and readmitted on [DATE]. The medical record included diagnoses not limited to dementia in other diseases classified elsewhere without behavioral disturbance, unspecified mood disorder due to known physiological condition, and unspecified schizoaffective disorder. A review of the physician orders for September 2021 for Resident #6 included the following: - Citalopram Hydrobromide tablet 20 milligram (mg) - Give one (1) tablet by mouth one time a day for depression, ordered 3/9/21. - Mirtazapine tablet 7.5 mg - Give 2 tablet by mouth at bedtime for depression. 2 tabs = 15 mg, ordered 8/26/21. Mirtazapine 15 mg ordered on 3/9/21 and scheduled for 9:00 a.m., the administration time was changed to 9:00 p.m. on 8/23/21. - Risperdal tablet 1 mg - Give 0.5 mg by mouth at bedtime for schizoaffective disorder, ordered 8/25/21. - Risperidone tablet 0.5 mg - Give 1 tablet by mouth in the morning for schizoaffective disorder. Behavior (BEH): 0) no, 1) fear, 2) anger, 3) scream, 4) danger/self/others, 5) delusions/hallucinations ([NAME]/[NAME]), 6) sad, 7)other description (desc). Interventions (INT): 1) Music, 2) Reminisce, 3) exercise (ex), 4) 1:1, 5) quiet, 6) as needed (prn). Outcome: I) Improved, S) Same, W) Worse. Side Effects (SE): 0) None, 1) Extrapyramidal Symptoms, 2) Tardive Dyskinesia, 3) Hypotension, $) Behavior (beh), 5) Drowsy, 6) Dizzy. This order was ordered on 6/9/21 for the diagnosis of psychotic disorder then changed on 8/17/21 for diagnosis of schizoaffective disorder. The above physician orders were discontinued on 9/22/21 related to the passing of Resident #6. The review of Resident #6's August and September 2021 Medication Administration Records (MAR) indicated that the physician order for the resident's Risperidone did not include areas for the staff to document the monitoring of behaviors, interventions, outcome and side effects. The MAR did not include monitoring for the antidepressant medications of Citalopram or Mirtazapine administered to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105591 If continuation sheet Page 18 of 29 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 09/23/2021 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident, the target behaviors the psychotropic medications were used to treat, or the time in which staff should be monitoring. The physician note, dated 9/21/21 at 12:12 p.m., indicated that Resident #6 had worsening pneumonia, with a Past Medical History (PMH) which included dementia. The note identified the resident was alert, very confused, and worsening dementia. The note did not identify behaviors related to the use of psychotropic medications. The facility was asked for Psychiatry notes for Resident #6 and the following notes were provided: - Psychiatry note, dated 6/5/21, indicated that services were reconsulted to assess meds for possible dose reduction of psychotropics. Patient (Pt) has done well recently with no agitation or disruptive behaviors she is cognitively impaired and has difficulty communicating. The plan was to attempt a dose reduction of Risperdal and consider a decrease in Remeron (Mirtazapine). - Psychiatry note, dated 7/6/21, identified that the patient was able to tolerate a decreased dose of Risperdal and remained disoriented and disorganized. 2. On 9/20/21 at 10:49 a.m., Resident #30 was interviewed while she sat in a wheelchair in the resident's room. The resident was observed, on 9/22/21 at 11:37 a.m. sitting in wheelchair applying body lotion. The admission Record for Resident #30 identified that the resident was admitted on [DATE] and diagnoses included unspecified encephalopathy, unspecified anxiety disorder, and cerebral infarction due to unspecified occlusion or stenosis of left cerebellar artery. A review of the September 2021 physician orders for Resident #30 included the following psychotropic medications: - Alprazolam tablet 0.5 milligram (mg) - Give 1 tablet by mouth every 8 hours as needed for anxiety until 9/26/21 x 14 days from 9/12/21. Revised 9/21/21. - Lexapro tablet 10 mg (Escitalopram Oxalate) - Give 10 mg by mouth at bedtime for depression. Revised 9/18/21. - Trazodone Hydrochloride (HCl) tablet 50 mg - Give 2 tablet by mouth at bedtime for insomnia. 2 tabs = 100 mg. Revised 9/21/21. A review of the September 2021 MAR did not indicate behaviors for the use of psychotropic medications were monitored. The active physician orders, dated 9/23/21 at 12:57 a.m., did not include orders for the monitoring of behaviors, side effects, outcomes, and non-pharmaceutical interventions related to the use of psychotropic medications. A request was made to the Director of Nursing (DON), on 9/22/21 at 6:57 p.m., for portions of Resident #30's clinical record which included the September 2021 Medication Administration Record (MAR) and Treatment Administration Record (TAR). The facility did not provide the September MAR or TAR but did provide other requested documentation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105591 If continuation sheet Page 19 of 29 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 09/23/2021 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 0758 The review of Resident #30's August 2021 MAR revealed the following: Level of Harm - Minimal harm or potential for actual harm - Lexapro 5 mg - Give 5 mg by mouth one time a day for anxiety, ordered 8/27/21 and discontinued on 9/18/21. The MAR did not indicate staff were documenting behaviors, non-pharmaceutical interventions, outcomes, or side effects related to use of Lexapro. Residents Affected - Few - Trazodone 50 mg - Give 2 tablet by mouth at bedtime for Insomnia. 2 tabs = 100 mg, ordered 4/2/21. The MAR did not indicate staff were documenting behaviors, non-pharmaceutical interventions, outcomes, or side effects related to use of Trazodone. - Alprazolam tablet 0.5 mg - Give 1 tablet by mouth every 8 hours as needed for anxiety for 14 day, ordered 7/30/21. --- a): The MAR did not indicate that staff had monitored for a target behavior or the resident had exhibited behaviors, interventions, outcomes or side effects related to the use of an as needed psychotropic medication. - Alprazolam tablet 0.5 mg - Give 1 tablet by mouth every 8 hours as needed from anxiety. Behavior (BEH) 0) No, 1) Fear, 2) Anger, 3) Scream, 4) Danger/Self/Others, 5) Delusions/Hallucinations ([NAME]/Hall), 6) Sad, 7) Other describe (desc). Interventions (INT): 1) Music, 2) Reminisce, 3) Exercise (ex), 4) 1:1, 5) Quiet, 6) as needed (prn). Outcome (OC): I) Improved (Imp), S) Same, W) Worse. Side Effects (SE): 0) none, 1) Extrapyramidal Symptoms (EPS), 2) Tardive Dyskinesia (Tard Dys), 3) Hypotension, 4) Behavior (beh), 5) Drowsy, 6) Dizzy. ordered 8/15 and discontinued 8/18/21. --- a): The MAR indicated that the staff had documented Not applicable (NA) on 8/15 and 8/16 for behaviors exhibited by the resident and did not indicate the medication had been monitored every shift. - Alprazolam tablet 0.5 mg - Give 1 tablet by mouth every 8 hours as ended by Anxiety x 14 days from 8/15 until 8/28/21. Behavior (BEH) 0) No, 1) Fear, 2) Anger, 3) Scream, 4) Danger/Self/Others, 5) Delusions/Hallucinations ([NAME]/Hall), 6) Sad, 7) Other describe (desc). Interventions (INT): 1) Music, 2) Reminisce, 3) Exercise (ex), 4) 1:1, 5) Quiet, 6) as needed (prn). Outcome (OC): I) Improved (Imp), S) Same, W) Worse. Side Effects (SE): 0) none, 1) Extrapyramidal Symptoms (EPS), 2) Tardive Dyskinesia (Tard Dys), 3) Hypotension, 4) Behavior (beh), 5) Drowsy, 6) Dizzy. ---a): The MAR indicated that staff had documented n on 8/18 for behavior, interventions, and Side effects and that administration was effective at 10:47 a.m., 0 on 8/20 for behavior, interventions, Outcomes, and Side effects and that the medication was effective on 8/19 at 11:08 a.m. and 8/20 at 6:39 p.m., Staff documented Not applicable (NA) on 8/21 - 8/26/21 for behavior, interventions, Outcomes, and Side effects while the medication had been administered with an effective outcome. - Alprazolam tablet 0.5 mg - Give 1 tablet by mouth every 8 hours as needed for anxiety, ordered 8/29/21 and discontinued 8/31/21. ---a): The MAR did not include an area for staff to document behaviors, interventions, outcomes or side effects. The review of Resident #30's care plan identified the resident had a diagnosis of depression and had the potential for adverse consequences of antidepressant medication, initiated and revised on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105591 If continuation sheet Page 20 of 29 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 09/23/2021 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 4/2/21. The interventions included: Monitor for effectiveness of medication, monitor for side effects of medication i.e.: nausea, gastrointestinal problems, dizziness, fatigue, dry mouth, weight gain, and insomnia, and monitor for signs and symptoms of depression and notify MD (doctor) prn (as needed). The care plan identified that the resident had a diagnosis of anxiety and had potential for adverse consequences related to use of Antianxiety and staff were instructed to monitor for effectiveness of medication and monitor for side effects of antianxiety medication i.e.: drowsiness, dizziness, weakness, dry mouth, diarrhea, nausea, constipation, blurred vision, and report to MD prn. A review of Daily Skilled Services notes, dated 9/12 - 9/20/21 indicated that staff had documented no changes to mood and behavior noted. The progress notes indicated that an order was added, 9/20/21, for Lexapro 10 mg, on 9/23/21 and the resident was placed on a three-day voiding trial, then on 9/23/21 related to speaking to the resident regarding medications found at bedside. The physician progress note, dated 9/14/21 at 6:49 p.m., did not identify a past medical history (PMH) of depression and the resident was alert/awake/oriented x3. The Psychiatric Consultation, dated 8/27/21, indicated the resident was diagnosed with depressive disorder. The consultation indicated the resident reported taking Xanax to prevent crying and admitted to sadness, and also reported taking Trazodone for insomnia with no behavioral issues reported. The psychiatric note, dated 9/18/21, indicated the resident did not note any difference in mood and denied side effects. The note indicated the resident continued to cry for no reason and relies on Xanax as needed to calm down. The note indicated the plan was to increase Lexapro to 10 mg at bedtime. The Director of Nursing (DON) was interviewed at 10:04 a.m. on 9/23/21. She stated that staff were monitoring behaviors and indicated the psych notes should be reviewed. A review of Resident #30's September MAR was completed with the DON. She confirmed that different psychotropic medications exhibit different side effects and the resident's MAR did not include any monitoring of target behaviors related to the continued use of Xanax and two antidepressants. She stated the facility did not separate monitoring of different classes of psychotropic medications. Staff T, Certified Nursing Assistant (CNA), stated, at 11:58 a.m. on 9/23/21, she was not caring for Resident #30 but did know her. She stated Resident #30 was real sweet, an able to tell them what she needs and did not have any behaviors and doesn't cry. During an interview with the Pharmacy Clinical Case Manager, at 12:59 p.m. on 9/23/21, he stated that staff should be documenting behaviors every shift and does not think it was necessary to separate the monitoring for different classes of psychotropic medications if they are used to treat the same behavior. The policy and procedures: Pharmacy Services - Drug Regimen Free from Unnecessary Drugs, issued and revised on 2/1/20, indicated the intent of this policy is each resident's entire drug/medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial wellbeing; the facility implements gradual dose reductions (GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and prn orders for psychotropic medications are only used when the medication is necessary and prn use is limited. The procedure indicated that each resident's drug regiment must be free from unnecessary drugs. An unnecessary drug is any drug when used: c. Without adequate monitoring; or d. without adequate indications for its use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105591 If continuation sheet Page 21 of 29 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 09/23/2021 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review, the facility failed to ensure that the medication error rate was less than 5.00%. Thirty-six medication administration opportunities were observed, and twenty-three errors were identified for three (#66, #90, and #58) of five observed residents. These errors constituted a 63.8% medication error rate. Residents Affected - Few Findings included: 1. On 9/21/21 at 8:23 a.m., an observation of medication administration with Staff Member C, Licensed Practical Nurse (LPN), was conducted with Resident #66. Staff C was observed administering the following medications: - Levetiracetam 1000 milligram (mg) tablet orally. - Metoprolol Tartrate 25 mg tablet orally. - Potassium Chloride (Cl) Extended Release (ER) 10 milliequivalent (meq) caplet orally. - Sodium Chloride (Cl) 1 gram (gm) tablet orally. The observation indicated that the pharmacy label of the blister-packaged Metoprolol indicated the medication was to be administered if vital signs were within parameters. The staff member stated that the Metoprolol doesn't have any parameters, nothing pops up (on the electronic Medication Administration Record (MAR)). Staff C crushed all the medications together and placed the items in applesauce. Staff C reported, on 9/21/21 at 8:39 a.m., that the resident would not take the Potassium without crushing it and that the resident did have liquid Potassium awhile ago but did not like the taste. A review of Resident #66's physician orders revealed the following: - Obtain vital signs every shift, ordered 11/18/20. - Metoprolol Tartrate Tablet 25 mg - Give 1 tablet by mouth every 12 hours for Hypertension (HTN). Hold for Systolic Blood Pressure (SBP) less than 110 or Heart Rate (HR) less than 60, ordered 11/18/20. - May crush medications unless contraindicated, ordered 11/17/20. The review of a Daily Skilled Services note, completed by Staff C and effective at 7:34 a.m. on 9/21/21, indicated the Most Recent Blood Pressure was 120/76 obtained at 11:58 p.m. on 9/20/21 from the left arm of Resident #66 while lying down. The Most Recent Pulse of 62 with a regular rate was also obtained at 11:58 p.m. on 9/20/21. The review of the Weights and Vital Summary indicated the following: - Blood pressure: 120/76 at 11:58 p.m. on 9/20/21 and the next recorded blood pressure of 135/91 was documented at 8:09 p.m. on 9/21/21. - Pulse: 62 beats per minute (bpm) at 11:58 p.m. on 9/20/21 and the next pulse of 75 was documented (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105591 If continuation sheet Page 22 of 29 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 09/23/2021 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 0759 at 8:09 p.m. at 9/21/21. Level of Harm - Minimal harm or potential for actual harm An interview was conducted with the Pharmacy Clinical Case Manager (CM), at 12:59 p.m. on 9/23/21. The CM stated that Potassium Chloride ER should not be crushed and in regards to obtaining a blood pressure and pulse, staff should obtain vital signs prior to the administration of the medication, and not use the ones obtained from the night before. Residents Affected - Few 2. On 9/21/21 at 11:31 a.m., an observation was made of Staff Member F, Licensed Practical Nurse (LPN), standing at a medication cart on the C-wing speaking with Staff Member I, Registered Nurse/Infection Control Preventionist (RN/ICP), the electronic Medication Administration Record identified the resident profiles colored red. Staff I stated she was helping Staff F due to being backed up, prior to the medication observation Staff I left the area. Staff F was observed administering the following medications to Resident #90: - Carvedilol 6.25 mg tablet orally - Misoprostol 200 microgram (mcg) tablet orally. - Sucralfate 1 gram (gm) tablet orally. - Lisinopril 40 mg tablet orally. - Enoxaparin Sodium 40mg/0.4 milliliter (mL) injection. The staff member confirmed he was administering 4 oral tablets. The staff member identified that the resident was to receive Folic Acid but after searching the medications received from pharmacy and over-the-counter medications he stated he was not able to locate it. He obtained blood glucose level from the resident during the administration and at 12:08 p.m., the nurse reviewed the insulin order and stated that the resident did not need to have insulin coverage. Immediately following the observation Staff Member F stated that the profile was red due to late medications and when medications were late he does look for someone to help. The staff member stated he did not get to the facility till 9:30 a.m., doing them a favor, normally works the 3-11 shift on the other unit, (A-wing) and that prior to his arrival staff had administered medications to one person on the assignment and that Staff I had begun to assist him one room ago. A review of the Medication Administration Record (MAR) for Resident #90 revealed the above medications were scheduled to be administered at 9:00 a.m. including Folic Acid 1 mg tablet orally. On 9/21/21 at 12:05 p.m., a review of the resident's MAR indicated that Staff F had documented that the Folic Acid prescribed to the resident had been administered. A further review of Resident #90's clinical record identified that a physician order had been obtained, on 9/22/21 at 12:54 p.m. ok to give all meds that were late for 9 a.m. 9/21/21. 3. On 9/22/21 at 12:09 p.m., Staff Member G, Licensed Practical Nurse (LPN), stated she was picking up shifts at this facility in the last week and that the medications were late because she was going to be on this unit or another but another nurse had not shown up then one came in so she was able to be on this hall. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105591 If continuation sheet Page 23 of 29 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 09/23/2021 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 0759 Level of Harm - Minimal harm or potential for actual harm Resident #58 confirmed, on 9/22/21 at 12:22 p.m., with Staff Member G that he wanted to take his medications, a lunch tray was sitting on the over-the-bed table in front of the resident. The staff member retrieved over-the-counter medications from the medication room then began dispensing the following medications at 12:31 p.m.: Residents Affected - Few - Breo Ellipta 100-25 mcg inhaler - Colace 100 mg tablet - Carvedilol 12.5 mg tablet - Desveniafaxine ER 25 mg tablet - Clopidogrel 75 mg tablet - Divaloproex DR 250 mg tablet - Eliquis 5 mg tablet - Gabapentin 400 mg capsule - Folic Acid 1 mg tablet - Isosorbide Mononitrate ER 30 mg tablet - Furosemide 40 mg tablet - Januvia 25 mg tablet - Pantoprazole DR 20 mg tablet - Potassium Cl ER 20 meq tablet - Tamsulosin Hydrochloride (HCl) 0.4 mg tablet - Novolog 100 unit/mL Flexpen 2 units The residents meal tray was removed from his room at 12:45 p.m., and at 12:56 p.m. Staff G obtained a blood glucose level of 173 from the resident. She handed the medication cup of oral medications to the resident, then the inhaler was administered and the staff member returned to the medication cart. She confirmed the amount of insulin needed, removed the Flexpen, applied a needle, and while holding the pen horizontally she dialed the dose selector to 2 units, returned to the residents room, and administered the 2 units in the residents right upper extremity. Immediately following the observation, Staff G stated she does not prime the Flexpen if she was able to see insulin coming from the needle after she selected 2 units. A review of the Medication Administration Record indicated that the above oral medications were due at 9:00 a.m. and the Novolog insulin was ordered before meals. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105591 If continuation sheet Page 24 of 29 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 09/23/2021 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The progress notes written by staff members on 9/22/21 did not indicate that the physician was notified that the residents' oral medication was administered 2.5 hours outside of the allowable time frame for administration and that the residents insulin was given after the resident had eaten lunch. During an interview with the Director of Nursing (DON), on 9/22/21 at 2:12 p.m., she stated that she was aware of Staff F's late medications and that a physician order was obtained, after the meds were given, that it was okay that the medications were late. She stated her expectation in regards to late meds was that the nurses were to administer the medications then to let the physician know that they were late, because staff wouldn't know they were late until they were late. She reported that the facility was aware they had a problem with late medications and was moving towards patient-centered liberalized medication administration times, such as day, afternoon, evening, and bedtime but that it was going to take 2 months. She stated the procedure for administration of insulin with a Novolog pen was to prime with 2 units, she reiterated to waste 2 units. The DON was asked to supply the facility's policy for medication administration. On 9/23/21 at 12:59 p.m., the Pharmacy Case Manager stated that the procedure for late medications depended on their policy but the window for scheduled 9 a.m. medications was between 8 a.m. and 10 a.m. and that the facility picked the scheduled time for medications. The Pharmacy policy (that the facility provided), General Dose Preparation and Medication Administration, effective 12/1/07 and revised 5/1/10 and 1/1/13, indicated that, Facility staff should also refer to facility policy regarding medication administration and should comply with applicable law and the State Operations Manual when administering medications. The policy instructed staff in the following: - Facility staff should crush oral medications only in accordance with pharmacy guidelines as set forth in Appendix 16: Common Oral Dosage Forms that Should Not Be Crushed and /or facility policy; - Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident, as set forth in Appendix 17: Facility Medication Administration Times Schedule; - Administer medications within timeframes specified by facility policy; Appendix 16: Common Oral Dosage Forms that Should Not Be Crushed, a Pharmacy policy copyrighted 2020, indicated that Potassium Chloride ER should not be crushed. The facility Clinical Competency regarding Insulin Injection, dated May 2017, identified, in section: Subcutaneous Insulin-Pen Device, that staff: - performs safety test prior to each injection, selects dose of units by turning dosage selector; - Takes off outer needle cap and keeps it to remove used needle following injection; - Takes off inner cap and discards it, holds pen with needle pointing upwards; - Taps insulin reservoir to move air bubbles put toward needle, presses injection button all the way in; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105591 If continuation sheet Page 25 of 29 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 09/23/2021 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 0759 - Checks if insulin comes out of the needle tip, repeats test until insulin is seen. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105591 If continuation sheet Page 26 of 29 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 09/23/2021 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, record reviews, and interviews the facility failed to ensure medications stored in three (A-Wing 3, C-Wing 1, and C-Wing 2) out of the six facility medication carts were stored appropriately as evidenced by narcotic medications not accounted for when administered and medications were not dated when opened when medications had a shortened shelf life. Findings included: Staff F, Licensed Practical Nurse (LPN) was observed, at 5:52 p.m. on 9/22/21, at the A-Wing nursing station. After reviewing the A-Wing Medication Cart 3 with Staff F. A full review of the controlled medications was made with Staff F and it was found that multiple narcotics had not been signed out when he had administered them. Four Controlled Medication Utilization Records for different residents were identified as not having the medications reconciled against the number of tablets/capsules available on the blister packages. (Photographic Evidence Obtained) Staff F stated he knew that the record should be signed off when the medication was administered but did not have time because the assignment had residents with multiple needs. An observation was conducted of the C-Wing Cart 1, on 9/22/21 6:19 p.m., with Staff U, Registered Nurse (RN). The observation revealed an Insulin Determine FlexTouch pen lying in a plastic basket, labeled with a resident name and without an open date. Staff U confirmed that the pen was not in a container and was undated. The RN stated, she was going to get her a bag for the pen and dated the pen 9/22/21. The observation revealed a Combivent Respimat inhaler that was not dated with an open date, which Staff U confirmed. Located in the same medication cart was another Combivent Respimat inhaler with a sticker that indicated it would need to be discarded 90 days after opening. (Photographic Evidence Obtained) On 9/23/21 at 12:59 p.m., the Pharmacy Clinical Case Manager (CC) stated that Combivent Respimat inhalers expire in 90 days after opening. An observation was made, 9/22/21 at 6:48 p.m., of the C-Wing Medication Cart 2 with Staff H, RN. The observation identified an opened, undated bottle of Fumigant eye drops, an opened, undated bottle of Brigandine eye drops, and a Novolog FlexTouch insulin pen undated as to when it was opened or when it would expire. The Staff H, RN and Staff I, RN, confirmed the findings. The staff members stated the resident who was prescribed the Novolog insulin pen had been discharged today. (Photographic Evidence Obtained) The Pharmacy CC stated, during an interview on 9/23/21 at 12:59 p.m., that both Fumigant and Brigandine eye drops expire 28 days after opening and should be dated when opened. The Pharmacy guidance, Medication Storage, identified the following: - Ophthalmic Products: Date when opened and discard unused portion after 28 days or in accordance with manufacturer's recommendations or facility policy. - Combivent Respimat Inhalation Spray: After initial assembly, the inhaler should be discarded after 3 months or when the locking mechanism is engaged, whichever comes first. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105591 If continuation sheet Page 27 of 29 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 09/23/2021 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 0761 - Novolog cartridge or pen: Room Temperature unopened- 28 days or Room Temperature opened- 28 days. Level of Harm - Minimal harm or potential for actual harm The policy: Storage and Expiration Dating of Medications, Biological's, Syringes, and Needles, effective 12/1/07 and later revised on 10/28/19, identified the following: Residents Affected - Few - Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened or opened. - When ophthalmic solutions and suspensions are opened the bottle should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened bottle. - Bedside Medication Storage: Facility should not administer/provide bedside mediations or biological's without a Physician/Prescriber order and approval by the Interdisciplinary Care Team and Facility administration. Facility should store bedside medications or biological's in a locked compartment within the resident's room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105591 If continuation sheet Page 28 of 29 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 09/23/2021 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation of dietary staff, interview with dietary staff, and review of dietary documents, the facility failed to ensure the kitchen equipment was maintained in a clean manner, items stored in the walk in refrigerator were dated and discarded when indicated by the date, the temperature and sanitation logs for the dish machine were accurately completed, and a floor drain was kept clean. Findings included: On 09/20/2021 at 10:00 a.m. a tour of the facility's main kitchen began. Staff J, Dietary Aide was standing at the dirty side of the dish machine and was observed to push a rack of dirty items into the dish machine. She was not able to answer questions about the dish machine so the Dietary Manager stepped in to answer. The temperatures of the dish machine met the standard per the manufacturer's guidelines, but the sanitizer strip did not change color to indicate the correct amount of sanitizer. The Dietary Manager checked the bucket of sanitizer and realized that the tubing was not in the sanitizer which did not allow the sanitizer to flow into the machine. The monitoring log for the dish machine was reviewed at that time and noted for having the three shifts for the day of temperature and sanitizer already documented. The Dietary Manager confirmed that someone must have just written in similar values to the other days and that it was incorrect to document the values prior to actually checking them. In addition at this time, the walk-in refrigerator located across from the range and oven was toured, and two gallon jugs both half full of mayonnaise were observed on a shelf in the refrigerator. Neither jug was labeled with the date that it had been opened. The manufacturer's date of production was not able to be determined as the date was encoded. A quarter steam table pan was observed toward the back of a shelf in the refrigerator topped with clear wrap which had the description of sloppy joe and the date of 09/07 scribbled on it in black marker. The Dietary Manager agreed that both jugs of mayonnaise should have been dated when opened and the sloppy joe should have been discarded after three days. In addition, the can opener attached to the cook's preparation table was noted to have a dark sticky substance on the pincer. The Dietary Manager reported that it had not yet been used that morning. An observation of the floor drain located between the ice machine and the reach-in freezer was noted to have standing water along the edges between the tile floor and the metal drain cover. The surface of the drain cover was slick when rubbed with the toe of a shoe. The inside drain was white and noted to be soiled with a black material. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105591 If continuation sheet Page 29 of 29