Health inspection·September 14, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, record review, and a review of facility training for all employees to include agency, the facility failed to honor the residents' right to be treated with dignity and respect, and failed to protect and value residents' private space by not knocking and asking for permission before entering the room for one (Resident #93) of two residents reviewed for dignity, from a total sample of 32 residents. The findings include: An interview was conducted with Resident #93 on 09/11/2023 at 11:58 AM. He was observed to be dressed and sitting upright in bed with the bed in its lowest position. He stated he was waiting for his lunch tray. During the interview, Agency Certified Nursing Assistant (CNA) A entered the room without knocking first or asking for permission to enter before entering. When CNA A was informed that an interview was being conducted, he continued into the room and stated Okay. CNA S was informed again that there was an interview in progress to which he replied Okay, I'm here to see the roommate, and continued walking toward Resident #93's roommate. When CNA A was asked whether he had been educated to knock on the resident's door and ask permission before entering, he stated, I'm Agency and I didn't know I needed to knock before entering a resident's room. He continued walking through the room. Resident #93 reported that the staff hardly ever knock before entering their room. A record review for Resident #93 found he was admitted to the facility on [DATE]. His diagnoses included type 2 diabetes mellitus, hyperlipidemia, depression, polyneuropathy, and history of transient ischemic attack (TIA). He had a quarterly Minimum Data Set (MDS) assessment with an assessment reference date of 07/16/2023, noting he had a brief interview for mental status (BIMS) score of 15 out of a possible 15 points, indicating he was cognitively intact and able to make daily decisions independently. He was documented as independent with all activities of daily living (ADLs) and required only set-up assistance from staff when tasks were completed. Another observation was made of CNA A on 09/12/2023 at 9:40 AM during the breakfast meal tray pass on the north unit. He entered rooms [ROOM NUMBERS] without knocking or asking the occupants' permission first while delivering meal trays. On 9/13/2023 at 2:00 PM, another observation was made of CNA A entering room [ROOM NUMBER] without knocking or asking the occupants' permission prior to entering their room. On 09/14/2023 at 10:39 AM, an interview was conducted with Agency Certified Nursing Assistant (CNA) J, who reported working consistently at the facility for two months. She stated she had worked as a Page 1 of 19 105682 105682 09/14/2023 Palm Garden of Jacksonville 5725 Spring Park Road Jacksonville, FL 32216

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few CNA since 2001. She further stated the facility provided her with education that included Resident Rights and Customer service. She defined dignity as giving the resident privacy and respecting their space. She stated the first thing she did before entering a resident's room was knock, introduce herself and identify the resident by their first name. She further stated, Knocking on the door is very big here, and the facility is always providing training on that. CNA J stated last week she received education about dignity and knocking on residents' doors, and before and after every shift they discussed customer service. On 09/14/2023 at 10:50 AM, an interview was conducted with Agency Licensed Practitioner Nurse (LPN) B, who reported working for the facility consistently that week on the medication cart. She reported receiving education and in-service training from the facility frequently on customer service, resident rights, and dignity. She further stated the facility provided reminders to the floor staff before and after their shifts to knock on residents' doors before entering. A facility policy and procedure on resident rights and dignity was requested from the Director of Nursing and the Regional Nurse. They both reported the facility didn't have a policy or procedure for Resident Rights or Dignity, but training was provided to staff including Agency staff that covered Resident Rights and Dignity. A review of the facility's In-service/Training Session/Team Meeting, held on 09/07/2023, where the topics of Customer Service and Appropriate Language were covered, revealed that CNA A was in attendance for this training. The in-service training forms provided did not identify specific Resident Rights covered or include education on the facility's policies related to Resident Rights and Dignity. . 105682 Page 2 of 19 105682 09/14/2023 Palm Garden of Jacksonville 5725 Spring Park Road Jacksonville, FL 32216

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 observations, staff and resident interviews, medical record review, and facility policy review, the facility failed to provide reasonable accommodation of resident needs for one (Resident #8) in a sample of 32 residents. The facility failed to ensure that the resident had their call light within reach and was able to use it if desired. Residents Affected - Few The findings include: On 09/11/23 at 11:10 a.m., Resident #8's call light was observed on the floor behind the right side of the head of his bed, out of reach. Resident #8 was non-verbal. He accurately answered yes/no questions by shaking or nodding his head. When asked if he could reach his call light, he shook his head no. (Photographic evidence obtained) On 09/11/23 at 1:23 p.m., the same call light was again observed on the floor behind the right side of the head of the bed, out of the resident's reach. On 09/12/23 at 8:01 a.m., Resident #8 was observed lying in bed. His call light was observed on the floor on the right side and underneath his bed. (Photographic evidence obtained) The resident was asked if he could reach his call light. He shook his head no. On 09/12/23 at 9:42 a.m., Resident #8 was observed lying in bed watching TV. His call light was observed on the floor on the right side and underneath his bed. (Photographic evidence obtained) Certified Nursing Assistant (CNA) C was asked to come into the room to assist the resident with his TV remote control. CNA C left the room after assisting with the TV remote control. She did not check for call light placement/accessibility. On 09/13/23 at 10:00 a.m., Resident #8 was observed lying in bed watching TV. His call light was observed tied to the bed rail on the right side of the bed. Resident #8 was asked if he could reach the call light. He nodded his head yes. He was asked if he used the call light when it was left within his reach. He nodded his head yes. He was asked if staff came to help him when he rang the call light. He nodded his head yes. He was asked to pick up his call light. He attempted to reach the call light with his left hand, but it was out of his reach. He was unable to use his right arm to attempt to reach the call light. (Photographic evidence obtained) On 09/13/23 at 1:53 p.m., Resident #8 was observed lying in bed with the head of his bed elevated. CNA A was observed in the room. He stated he had just finished assisting Resident #8 to eat his lunch. The call light was observed attached to the bed rail on the right side of the bed. Resident #8 was asked if he could reach the call light. He attempted to reach the call light with his left hand, but it was out of his reach. He was unable to use his right arm to attempt to reach call light. CNA A was asked about call light placement for residents. He stated, It should be left in reach if they are alert and oriented. In a medical record review for Resident #8, it was revealed that his diagnoses included hemiplegia and hemiparesis following unspecified cerebral vascular disease affecting his right dominant side. He was also diagnosed with Parkinson's disease, contracture of muscle (right hand), and aphasia following non-traumatic intracerebral hemorrhage. 105682 Page 3 of 19 105682 09/14/2023 Palm Garden of Jacksonville 5725 Spring Park Road Jacksonville, FL 32216

F 0558 In a review of the quarterly Minimum Data Set, dated [DATE], it was revealed that Resident #8 was assessed as: Level of Harm - Minimal harm or potential for actual harm B: Hearing: adequate (no difficulty in normal conversation, social interaction, listening to TV) Residents Affected - Few Speech Clarity: no speech (absence of spoken words) Makes self understood: sometimes understood (ability is limited to making concrete requests) Ability to understand others: sometimes understands (responds adequately to simple, direct communication only) Vision: adequate (sees fine detail, such as regular print in newspaper/books) Functional Status: G: bed mobility: extensive assistance/1 person physical assist transfers: extensive assistance/2 person physical assist dressing: extensive assistance/1 person physical assist eating: extensive assistance/1 person physical assist toileting: extensive assistance/1 person physical assist A review of the person-centered care plan for Resident #8 revealed: Focus: (2/7/19, revised 5/16/23) Resident has a history of falls and is at risk for further falls and fall related injuries. Goal: Resident will have injuries related to a fall minimized through the next review date. Interventions: Encourage to use call light. Focus: (10/9/18, revised 4/19/23) Resident has ADL (activities of daily living) self care deficit related to limited mobility, history of cerebral vascular accident with right hemiplegia. Goal: Will not develop complications related to decreased ADL self performance. Interventions: Encourage to use call light for assistance. A review of the facility's policy for Call Light, Answering (effective 10/2014) revealed: Purpose: The purpose of this procedure is to respond to the resident's requests and needs. Key procedural points: 4. When the resident is in bed or confined to a chair, be sure the call light is within easy reach 105682 Page 4 of 19 105682 09/14/2023 Palm Garden of Jacksonville 5725 Spring Park Road Jacksonville, FL 32216

F 0558 of the resident. Level of Harm - Minimal harm or potential for actual harm Procedure: 5. Position the call light within easy reach of the resident. Residents Affected - Few . 105682 Page 5 of 19 105682 09/14/2023 Palm Garden of Jacksonville 5725 Spring Park Road Jacksonville, FL 32216

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, and staff interview, the facility failed to ensure residents' personal privacy during medical treatment for one (Resident #50) of six residents observed during medication administration. Resident #50 was not provided privacy during medication administration via her gastrostomy tube (feeding tube). Each resident has the right to privacy and confidentiality for all aspects of care and services. A nursing home resident has the right to personal privacy of his or her own physical body. Residents Affected - Few The findings include: On 09/14/23 at 8:50 a.m., Licensed Practical Nurse (LPN) B was observed preparing medications for Resident #50. A review of the resident's medication orders revealed that all of her medications were administered through her gastrostomy tube (feeding tube). LPN B was observed administering three medications to Resident #50 via her gastrostomy tube. During the medication administration, the resident's bedcovers were pulled down and her hospital gown was pulled up, exposing the resident's abdomen and upper thighs. The resident was observed in the bed next to a large picture window which faced the facility parking lot area. The window shade was observed to be up to the top of the window. While administering the medications, two people were observed to walk by the window at two separate times. When medication administration was completed, the nurse was asked how she provided privacy to a resident receiving gastrostomy tube services. She stated, I pull the privacy curtain. She was asked why the curtain was not pulled to obstruct the view to the inside of the room from the window. She stated, Oh I should have pulled the curtain around the bed or pulled the blinds. . 105682 Page 6 of 19 105682 09/14/2023 Palm Garden of Jacksonville 5725 Spring Park Road Jacksonville, FL 32216

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observations, staff interviews, medical record review, and facility policy review, the facility failed to maintain a clean and sanitary homelike environment for four (Residents #50, #1, #3, and #87) of seven residents receiving enteral nutrition. Sanitary includes, but is not limited to, preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored. It is the responsibility of all facility staff to create a homelike environment and promptly address any cleaning needs. The findings include: 1. On 09/11/23 at 11:30 a.m., Resident #50 was observed lying in bed connected to a running tube feeding pump. Her tube feeding pump and the pole it was attached to were observed to be covered in beige debris along the entire pole (Photographic evidence obtained); and the tube feeding pump was observed with beige debris on the pump device. (Photographic evidence obtained) On 09/12/23 at 6:06 a.m., Resident #50 was observed lying in bed connected to a running tube feeding pump. Her tube feeding pump and the pole it was attached to were observed to be covered in beige debris along the entire pole (Photographic evidence obtained); and the tube feeding pump was observed with beige debris on the pump device. (Photographic evidence obtained) On 09/13/23 at 9:51 a.m., Resident #50 was observed lying in bed connected to a running tube feeding pump. Her tube feeding pump and the pole it was attached to were observed to be covered in beige debris along the entire pole (Photographic evidence obtained); and the tube feeding pump was observed with beige debris on the pump device. (Photographic evidence obtained) On 09/14/23 at 8:26 a.m., Resident #50 was observed lying in bed connected to a running tube feeding pump. Her tube feeding pump was observed with beige debris on the pump device. (Photographic evidence obtained) 2. On 09/11/23 at 11:18 a.m., Resident #1 was observed lying in bed connected to a running tube feeding pump. Her tube feeding pump and the pole it was attached to were observed to be splattered in beige debris along the entire pole (Photographic evidence obtained); and the tube feeding pump was observed with beige debris caked onto the pump device. (Photographic evidence obtained) On 09/12/23 at 5:55 a.m., Resident #1 was observed lying in bed connected to a running tube feeding pump. Her tube feeding pump and the pole it was attached to were observed to be splattered in beige debris along the entire pole. Her tube feeding pump was observed with beige debris caked onto the pump device. (Photographic evidence obtained) On 09/13/23 at 9:49 a.m., Resident #1 was observed lying in bed connected to a running tube feeding pump. Her tube feeding pump and the pole it was attached to were observed to be splattered in beige debris along the entire pole. Her tube feeding pump was observed with beige debris caked onto the pump device. (Photographic evidence obtained) On 09/14/23 at 8:10 a.m., Resident #1 was observed lying in bed connected to a running tube feeding pump. Her tube feeding pump was observed with beige debris caked onto the pump device. (Photographic evidence obtained) 105682 Page 7 of 19 105682 09/14/2023 Palm Garden of Jacksonville 5725 Spring Park Road Jacksonville, FL 32216

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3. On 09/11/23 at 9:49 am, Resident #3 was observed lying in his bed connected to a running tube feeding pump. His tube feeding pole was observed to have beige splatter along the pole and on the base of the pole. (Photographic evidence obtained) 4. On 09/11/23, at 12:57 p.m., Resident #87 was observed lying in her bed connected to a running tube feeding pump. Her tube feeding pole was observed to have beige splatter along the pole. (Photographic evidence obtained) Beige splatter was also observed on the wall behind the pole. (Photographic evidence obtained) A medical record review for Residents #50, #1, #3, and #87 revealed that each of these residents had current orders for continuous enteral nutrition. On 09/13/23 at 3:00 p.m., in an interview with the Director of Nursing, she was asked who was responsible for cleaning resident care equipment such as tube feeding pumps and tube feeding pump poles in resident rooms. She stated the staff caring for the residents were responsible. She was asked to observe the tube feeding pumps and tube feeding pump poles for Residents #1 and #50. Upon entering the rooms and observing the beige debris on the tube feeding pumps and tube feeding poles of each of the two residents, she was asked if they were expected to be in this state of uncleanliness. She stated no. She was asked who was responsible for cleaning this type if patient care equipment. She stated the staff caring for the residents were responsible. A review of the facility's policy for Resident Room Cleaning (effective date 11/2022) revealed: Policy: All resident rooms should be cleaned as needed and/or daily. A review of the facility's policy for Infection Prevention and Control Manual: Resident Care Equipment (effective date Dec. 2020) revealed: Purpose: Reusable equipment is to be cleaned between resident use and reprocessed appropriately. The facility must protect indirect transmission through decontamination (ie cleaning, sanitizing, or disinfecting) of an object to render it safe for handling. Equipment: Infusion pumps (IV, feeding pumps) Frequency: When visible soiled and between residents. Accountability: As per assigned by by facility. . 105682 Page 8 of 19 105682 09/14/2023 Palm Garden of Jacksonville 5725 Spring Park Road Jacksonville, FL 32216

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observations, staff and resident interviews, medical record review, and facility policy review, the facility failed to provide services which met professional standards of quality, specifically leaving medications unattended at the resident's bedside, for four (Residents #12, #33, #105, and #50) of six residents observed during medication administration, from a total of 32 residents sampled. Professional standards of quality means that care and services are provided according to accepted standards of clinical practice. Residents Affected - Some The findings include: On 9/11/23 at 1:35 pm, Resident #12 was observed lying in her bed. A medication cup was observed on the tray table in front of the resident. Two pills were observed in the cup. (Photographic evidence obtained) There were no staff observed in the room. She stated the medication was hers. She stated the pills were Gabapentin and Darvocet. When asked when the medications were brought to her or when they were scheduled to be taken, she stated, No one is on a schedule around here. On 9/12/23 at 7:30 am, Resident #12 was observed lying in her bed. A white round pill was observed on her bed to her right. (Photographic evidence obtained) The pill was observed to have the letters RP on one side and 10/325 on the other side. The resident was asked if she knew there was a pill in her bed. She stated, No, I didn't know that. I don't know what that is. I had a pain pill earlier, but I don't think that's my pain pill. She was asked not to take the pill, but to drop it into a medication cup for the nurse to see. Registered Nurse (RN) D was asked to come to Resident #12's room. He was shown the pill and advised that the pill was just found on the resident's bed. He stated, I don't know what that is. I will take it away. He was asked if he could identify what the pill was. He said no. He was asked if he knew how to identify the pill. He brought the pill to his medication cart and looked up the pills on his medication cart computer. He was able to identify the pill by looking at the eMAR (electronic medication administration record) photographs and by comparing the pill to the resident's pill card in the medication cart. He stated the pill was a Percocet Tablet 10/325 mg (milligrams). He stated the pill was signed out from the eMAR at 5:46 am this morning. He stated this was signed out before he came in for his shift today. He then wasted the Percocet tablet with Licensed Practical Nurse (LPN) I. On 9/13/23 at 9:12 am, during medication pass administration observations, LPN E was observed preparing medication for Resident #33. After entering the resident's room, the nurse placed the medications on the resident's night stand next to her bed and stated, I have to go get something. She left the room, leaving the medications unattended and returned 90 seconds later stating, I forgot a spoon. After medication pass was completed, she was asked why she left the medications unattended in the resident's room. She stated, I don't know. I had to get a spoon. I just thought because you were there? I shouldn't have done that? On 9/14/23 at 8:20 am, during medication pass administration observations, LPN B was observed preparing medication for Resident #50. After entering the resident's room, the nurse placed the medications on the resident's bedside table next to her bed and stated, Oh, I need gloves. She left the room, leaving the medications unattended and returned 60 seconds later. She started her task and then stated, I need to get more water, I'll be right back. She returned two minutes later and proceeded to flush the gastrotomy tube. She then stated, I need more gloves, I'll be right back. She returned after two minutes and completed the medication administration for Resident #50. After medication pass was completed, she was asked why she left the medications unattended in the resident's room. She 105682 Page 9 of 19 105682 09/14/2023 Palm Garden of Jacksonville 5725 Spring Park Road Jacksonville, FL 32216

F 0658 stated, I just forgot to get gloves and water. Level of Harm - Minimal harm or potential for actual harm On 9/14/23 at 9:05 am, during medication pass administration observations, LPN F was observed preparing medications for Resident #105. After preparing the medications and entering resident's room, but before administering medications, the nurse stated, I have to go get some water. She took the medication cup with her and stated, I'll take the pills with me, he won't touch the insulin pen. The insulin pen was observed left on the resident's bedside table, unattended, while LPN F was not in the room for two minutes. Residents Affected - Some A review of the facility's policy for Medication Administration (dated 7/2023) stated: Purpose: To administer the following according to principles of medication administration, including the right medication, to the right guest/resident at the right tine, and in the right dose and route. Procedure: 16. Remain with the guest/resident until all medication is taken. . 105682 Page 10 of 19 105682 09/14/2023 Palm Garden of Jacksonville 5725 Spring Park Road Jacksonville, FL 32216

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and review of facility training, the facility failed to ensure that a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for one (Resident #107) of three residents reviewed for ADLs, from a total sample of 32 residents. Residents Affected - Few The findings include: On 09/11/2023 at 11:19 AM, Resident #107 was observed in her room lying in bed. Her hands were exposed and her fingernails were noted to be long in length, with dark colored debris between the fingertips and fingernails. When greeted, she reported she was legally blind but could see shadows. When asked if she preferred her fingernails at the current length, she stated no, she felt they were too long but didn't want to cause any problems. (Photographic evidence obtained) A review of the medical record revealed that Resident #107 was admitted to the facility on [DATE]. Her diagnoses included surgical aftercare following surgery on the digestive system, altered mental status, cholecystitis, encephalopathy, end stage renal disease, dialysis, unspecified dementia, and major depression. A review of the five-day minimum data set (MDS) assessment, dated 07/15/2023, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 possible points, indicating the resident had moderate cognitive impairment with the ability to make herself understood, and had the ability to understand others. Resident #107 was also assessed to require extensive assistance with bed mobility, dressing, eating and personal hygiene. Her vision was noted to be severely impaired. On 09/12/2023 at 9:19 AM, Resident #107 was again observed in her room lying in her bed. Her fingernails were noted to be long in length with black debris in-between the fingertips and fingernails. (Photographic evidence obtained). Resident #107 was care planned on 06/05/2023 for needing assistance with ADLs, with a goal to not develop any complications related to ADL self-performance. Interventions included bathing preference shower and/or bed bath and to provide assistance/supervision as needed. The care plan did not reflect any focus or goals related to nail care, grooming and hygiene. (Photographic evidence obtained) On 09/14/2023 at 10:31 AM, Resident #107 was observed for a third time in her room. She was lying in her bed and reported she was cleaned up the other day. When asked if her fingernails were cleaned and trimmed, she held both hands up and stated they're still here, showing her nails that still appeared long in length with dark colored debris between the fingertips and fingernails. She reported no one had checked her fingernails, and no one had offered to trim them. (Photographic evidence obtained) During an interview on 09/14/2023 at 10:40 AM with Agency Certified Nursing Assistant (CNA) J, she stated she was familiar with Resident #107. She stated the resident required one person to assist due to her vision impairment and did not refuse care. She went on to report that Resident #107's assigned CNA would provide hand care daily to include soaking the nails and filing or trimming them if needed. CNA J further stated on scheduled shower/bath days, the skin, to include fingernails and toenails, was focused on unless the resident was diabetic, then she would inform the nurse. 105682 Page 11 of 19 105682 09/14/2023 Palm Garden of Jacksonville 5725 Spring Park Road Jacksonville, FL 32216

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview with Agency Licensed Practical Nurse (LPN) B on 09/14/2023 at 10:51 AM, confirmed that when the CNAs rounded at the start and end of each shift, they checked the residents' skin integrity, hygiene (to include shaving), nail care, and oral care, and over-all needs. She further stated any concerns were reported to the nurse and the CNAs would document. On 9/14/2023 at 11:25 AM, an interview with Resident #107's family member and health care surrogate, revealed that the family visited with the resident at least once a week since her admission, and they requested that Resident #107's fingernails be cleaned and trimmed more than two weeks ago. Further, the facility informed the family member that the resident's nail care was completed on Tuesdays, the residents scheduled shower day, however, the family member reported that when they visited last week, this task was still not completed. A review of the facility's in-service training session/team meeting dated 08/30/2023, revealed session topics covered included ADL Care to Resident; no facial hair, nails cleaned, check resident beginning of shift, throughout shift, and assist as needed with all care needs. The attendance form included nine Certified Nursing Assistants' signatures. The Director of Nursing and Regional Registered Nurse reported the facility did not have a policy or procedure for ADL Care. . 105682 Page 12 of 19 105682 09/14/2023 Palm Garden of Jacksonville 5725 Spring Park Road Jacksonville, FL 32216

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observations, staff and resident interviews, medical record review, and facility policy review, the facility failed to ensure disposition of medications for two (Resident #12 and Resident #105) six residents observed during administration of medications, from a total of 32 residents sampled. Method of disposition (including controlled medications) should prevent diversion and/or accidental exposure and is consistent with applicable state and federal requirements, local ordinances, and standards of practice. The findings include: 1. On 9/12/23 at 7:30 am, Resident #12 was observed lying in her bed. A white round pill was observed on her bed to her right. (Photographic evidence obtained) The pill was observed to have the letters RP on one side and 10/325 on the other side. The resident was asked if she knew there was a pill in her bed. She stated, No, I didn't know that. I don't know what that is. I had a pain pill earlier, but I don't think that's my pain pill. She was asked not to take the pill, but to drop it into a medication cup for the nurse to see. Registered Nurse (RN) D was asked to come to Resident #12's room. He was shown the pill and advised that the pill was just found on the resident's bed. He stated, I don't know what that is. I will take it away. He was asked if he could identify what the pill was. He said no. He was asked if he knew how to identify the pill. He brought the pill to his medication cart and looked up the pills on his medication cart computer. He was able to identify the pill by looking at the eMAR (electronic medication administration record) photographs and by comparing the pill to the resident's pill card in the medication cart. He stated the pill was a Percocet Tablet 10/325 mg (milligrams). He stated the pill was signed out from the eMAR at 5:46 am this morning. He stated this was signed out before he came in for his shift today. He then wasted the Percocet tablet with Licensed Practical Nurse (LPN) I. LPN I stated, We don't have any Drug Buster on the cart, I'll just toss it in the sharps container. She was observed to place the medication identified as Percocet into the sharps container attached to the medication cart. A medical record review for Resident #12 revealed an order which stated: Percocet 10/325 mg (milligrams), one tablet by mouth every 4 hours as needed for pain. A review of the resident's eMAR (electronic medication administration record) revealed one Percocet tablet 10/325 mg was signed out as having been administered on 9/12/23 at 5:46 am. 2. On 09/14/23 at 9:05 am, LPN F was observed preparing medications for Resident #105. She removed a Vitamin D tablet from a bottle and stated, Oh wait, that's the wrong dose. She was observed tossing the tablet into the sharps container attached to her medication cart. She continued preparing the medications. She brought the medications to Resident #105. While telling him which medications she was giving him, the resident stated he did not want the Colace. LPN F removed the Colace from the medication cup. When she returned to her medication cart, she tossed the Colace tablet into the sharps container attached to her medication cart. In an interview with LPN F on 9/14/23 at 9:20 am, she was asked how she disposed of medications that are not administered. She stated, I don't think we have the drug buster containers here, so I toss them into the sharps container. I don't want to throw them in the trash because someone could dig them out of the trash. She was asked what the facility's policy for disposing of medications was. She 105682 Page 13 of 19 105682 09/14/2023 Palm Garden of Jacksonville 5725 Spring Park Road Jacksonville, FL 32216

F 0755 stated, I don't know, I just know I wouldn't throw them in the trash. Level of Harm - Minimal harm or potential for actual harm On 9/14/23 at 11:20 am, in an interview with the Administrator, she was asked what the facility's non-retrievable drug disposal system was, as outlined in their Medications Destroying policy. She stated she would need to have the Director of Nursing (DON) answer that. Residents Affected - Few On 9/14/23, at 12:30 pm, the DON was asked what the facility;s non-retrievable drug disposal system was, as outlined in their Medications Destroying policy. She stated, We're going to order some more of these (indicating a bottle labeled drug destroyer she was holding) to have one on each cart and we will in-service all staff. She was asked if this product was available on all the medication carts now. She stated, No, we only have this one bottle, we're ordering them now. A review of the facility's policy for Medication, Destroying (effective date October 2014) revealed: Purpose: The purpose of the procedure is to establish uniform guidelines concerning the destruction of medications. General Guidelines: 5. Unless otherwise instructed, discard tablets, capsules, liquids, patches, and contents of vials and ampules in the facility's non-retrievable drug disposal system. . 105682 Page 14 of 19 105682 09/14/2023 Palm Garden of Jacksonville 5725 Spring Park Road Jacksonville, FL 32216

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, and facility policy and procedure review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety, by failing to 1) Ensure sanitary storage of bulk food items, 2) Ensure baking pans were air dried, and 3) Ensure that the ice and water dispensing machine used for residents' drinks in the nourishment room, was clean and sanitary. The findings include: During the initial tour of the kitchen on 09/11/23 at 11:30 AM, wet nesting of large baking pans was observed on the storage rack. The bulk flour bin had a plastic bowl lying in the product. The bulk sugar bin had a Styrofoam drinking cup lying in the product. The bulk rice bin had a plastic plate lying in the product. (Photographic evidence obtained) During a subsequent tour of the kitchen on 09/13/23 at 12:50 PM, wet nesting of large baking pans was observed on the storage rack. During an interview with the Dietary Manager on 09/13/2023 at 12:55 PM, she agreed that the pans were wet nesting and that the facility did not have a lot of space or racks for the pans to air dry after washing. She stated the bulk storage bins should not have scoops left in the product and scoops used for bulk storage bins should have a handle. During a 09/13/2023 tour of the nutrition rooms on each nursing unit between 1:00 PM and 2:00 PM, the ice/water dispensing machine located on the South Unit had black biological growth on the spout. (Photographic evidence obtained) During a 09/13/2023 interview with the Unit Manager of the South Unit, Registered Nurse (RN) K, at 2:15 PM, she observed the ice/water dispenser and stated it appeared to have mold growing on it. She confirmed that the machine was used to fill water cups for the residents. During an interview with the Maintenance Director on 09/13/2023 at 2:28 PM, he stated it was his responsibility to clean the ice/water dispenser in the nourishment room. He was not certain of the last time he had done so. A review of the facility's policy and procedure titled Infection Prevention and Control Manual. Ice Chests and Machines. (Effective date: December 2020), revealed: Purpose: Ice may become contaminated from the use of impure water, contamination of ice-making machines, or from improper storage or handling of ice. Policy: It is the policy of this facility to keep the ice machine clean and sanitary to help prevent contamination of the ice. Cleaning the ice machine or ice chest using the manufacturer's guideline/recommendations: 4. Clean the ice machine on a regular schedule, at least quarterly. 5. Thoroughly clean machine and parts with water and detergent. Reference: 3-304.12 In-Use Utensils, Between-Use Storage. During pauses in food preparation or dispensing, food preparation and dispensing utensils shall be 105682 Page 15 of 19 105682 09/14/2023 Palm Garden of Jacksonville 5725 Spring Park Road Jacksonville, FL 32216

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many stored: (A) Except as specified under (B) of this section, in the food with their handles above the top of the food and the container; (B) In food that is not time/temperature control for safety food with their handles above the top of the food within containers or equipment that can be closed, such as bins of sugar, flour, or cinnamon. FDA Food Code 2022 Chapter 3 Food. 3-304.12 In-Use Utensils, Between-Use Storage. Page 13. https://www.fda.gov/food/fda-food-code/food-code-2022. 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use (B) Clean equipment and utensils shall be stored as specified under (A) of this section and shall be stored: (1) In a self-draining position that allows air drying. FDA Food Code 2022 Chapter 4 Equipment, Utensils, and Linens. 4-903 Storing. 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. Page 28. https://www.fda.gov/food/fda-food-code/food-code-2022. 4-602.11 Equipment Food-Contact Surfaces and Utensils Surfaces of utensils and equipment contacting food that is not time/temperature control for safety food such as iced tea dispensers, carbonated beverage dispenser nozzles, beverage dispensing circuits or lines, water vending equipment, coffee bean grinders, ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms. Some equipment manufacturers and industry associations, e.g., within the tea industry, develop guidelines for regular cleaning and sanitizing of equipment. If the manufacturer does not provide cleaning specifications for food-contact surfaces of equipment that are not readily visible, the person in charge should develop a cleaning regimen that is based on the soil that may accumulate in those particular items of equipment. FDA Food Code 2022 Annex 3. Public Health Reasons/Administrative Guideline. 4-602.11 Equipment Food-Contact Surfaces and Utensils. Page 177. https://www.fda.gov/food/fda-food-code/food-code-2022. . 105682 Page 16 of 19 105682 09/14/2023 Palm Garden of Jacksonville 5725 Spring Park Road Jacksonville, FL 32216

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, facility document review, staff interview, manufacturer's specifications review, and facility policy and procedure review, the facility failed to ensure essential mechanical equipment in the kitchen was maintained in a safe operating condition, as evidenced by the dish machine not functioning according to manufacturer's specifications to ensure dishware was sanitized properly. Failure to properly wash and sanitize glassware and dishes used by residents presents the potential for pathogen exposure and negative health outcomes. Residents Affected - Many The findings include: During the initial tour of the facility kitchen on 09/11/23 at 11:30 AM, Dietary Staff Member G was operating the dish machine. The temperature gauge was observed. The wash cycle temperature went to 112 degrees Farenheit (F). The rinse cycle temperature was observed to go to 112 degrees F. The gauge did not move during the cycles. On the front side of the dish machine a metal plaque was observed to read: Wash cycle minimum temperature: 120 degrees F, Rinse cycle minimum temperature: 120 degrees F, Sanitizer 50 ppm (parts per million). Dietary Staff Member G was asked to test the sanitizer level. She took a test strip out of the container of test strips and stated she was going to dip the test strip into the pooled water inside the bottom of the machine. She stated she did not know that doing so would give a false reading of the level of sanitizer in the water. She then stated she would run the test strip along the edge of the door to the dish machine. She was asked to test the sanitizer at the level of the plate/glass being sanitized. When she put the test strip inside of a glass, it registered zero ppm of chlorine in the water. (Photographic evidence obtained) The employee confirmed that the test strip did not register any chlorine in the water. She stated she had been doing dishes for at least one hour and had run multiple loads of dishes through the machine. She stated she did not inform the Dietary Manager (DM) because she was unaware of the problem. She confirmed that she had not tested the sanitizer level during the process of washing the breakfast dishes. A review of the dish machine temperature log for the month of September 2023 revealed that the staff had recorded the breakfast meal wash cycle temperature to be 181 degrees F on 09/01/2023, 09/03/2023, and 09/04/2023. They recorded the wash cycle to be 180 degrees F on 09/02/2023 and 179 degrees F on 09/05/2023 through 09/10/2023. The rinse cycle had been recorded at 178 degrees F on 09/01/2023 through 09/04/2023. It was recorded to be 176 degrees F on 09/05/2023 and 175 degrees F on 09/06/2023 through 09/10/2023. The lunch meal temperatures were 179 degrees F each day for the wash cycle and the rinse cycle temperatures varied between 175 degrees F and 185 degrees F. The sanitizer level had been recorded to be 50 ppm each day for each meal. (Photographic evidence obtained) During an interview with the Dietary Manager (DM) on 09/11/2023 at 11:45 am, she observed the gauge on the dish machine and confirmed that the temperature was not reaching 120 degrees F for either the wash or rinse cycles. She stated she asked Dietary Staff Member G if she had tested the sanitizer level this morning, and she told her no, she had not. The DM stated she had given the staff training on how to run the dish machine and test the sanitizer level prior to washing the dishes after each meal. She stated she would call the contracted provider for maintenance of the dish machine immediately. She reviewed the temperature log and stated the staff needed to have more training. During a second tour of the kitchen on 09/12/23 at 10:09 am, the dish machine was not being used. The DM was asked to run the machine and test the sanitizer level. She ran one cycle. The wash cycle was 112 degrees F. The rinse was 112 degrees F. She went over to the heat booster and turned it on. She then ran the machine again (2nd time). The wash cycle temp was 112 degrees F and the rinse cycle 105682 Page 17 of 19 105682 09/14/2023 Palm Garden of Jacksonville 5725 Spring Park Road Jacksonville, FL 32216

F 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many was 112 degrees F. She stated she just turned on the heat booster and it needed to heat up. She ran the machine again (3rd time). The wash temp reached 112 degrees F and the rinse cycle was 118 degrees F. She ran it a 4th time and the wash cycle was 112 degrees F and the rinse cycle reached 120 degrees F. The DM was asked to test the sanitizer level. She opened the machine and took a test strip out of the canister. She stated she was going to run the test strip along the edge of the machine door. She was instructed to test the level on a dish or glass. The DM tested the sanitizer level. It was 100 ppm. She ran the machine one more time and the wash cycle reached 115 degrees F and the rinse cycle reached 123 degrees F. She stated the maintenance technician from the contracted provider had come to the facility yesterday to fix the machine and she thought it had been fixed. The temperature gauge never reached 120 degrees F during the wash cycle. She pointed to the tubing coming out of the chlorine drum on the floor next to the dish machine and stated that the tubing was not down in the drum far enough yesterday for the cholrine to go up into the dish machine. The technician applied a black plastic tie-off to the tubing to ensure it would not come up out of the drum. The Registered Dietician entered the dish room and stated the machine was old and needed to be run a couple of times before dishes were run through. At that point the heat booster started to steam excessively. The DM called the Maintenance Director immediately. When the Maintenance Director entered the dish room, he looked at the back of the heat booster and stated the booster overheated and when that happened there was a safety valve that would release steam. He instructed the DM to call the technician to come to the facility to check the booster. She explained that the machine was fixed yesterday and worked fine, but the temperature gauge did not reach 120 degrees F during the wash cycle. She then immediately called the Maintenance Provider. During an interview with the Administrator on 09/13/23 at 10:34 AM, she stated she had been made aware of the dish machine not working properly. It's still not working. We are having the heat booster worked on. It blew a gasket. The [Maintenance provider] is on site. During a third tour of the kitchen on 09/13/23 at 11:40 AM, the technician from the maintenance provider was on site in the dish room speaking with the Administrator. He had a temperature gauge tester attached to the gauge on the machine. The machine was running. The wash cycle reached 123 degrees F and the rinse cycle reached 120 degrees F. He was heard telling the DM that the machine would need to run several times to bring the hot water over from the hot water heater, and after it reached the right temperature, there should be no problem. The DM stated she would provide an in-service training on the proper way to run the dish machine today. During a fourth tour of the kitchen on 09/14/2023 at 10:23 am, the dish machine was observed for two loads of dirty dishes. Dietary Staff Member H was running the machine. The wash cycle went up to 112 degrees F and the rinse cycle went up to 116 degrees F for both cycles. The DM was standing in the dish room making the same observation. She stated, The technician was just here again yesterday and I promise it was working fine. Dietary Staff Member H stated, I've been running it like this all morning. She confirmed that she had run multiple loads of dishes through the machine. She confirmed that she was unaware of the problem and had not reported it to the DM. A review of the manufacturer's specifications for the dish machine entitled ES-4000 Dishmachine revealed: Operating temperatures: Wash (minimum) 120'F Sanitizing rinse (minimum) 120'F. (Copy obtained) A review of the facility's policy and procedure titled Low Temp Dishmachine Guidelines (LTDG 2.11.16) revealed the following: Set-up Procedures: Close drains and doors. Fill machine according to manufacturer's filling procedures. Typical wash and rinse temperatures for Low Temp Machine 120 degrees 105682 Page 18 of 19 105682 09/14/2023 Palm Garden of Jacksonville 5725 Spring Park Road Jacksonville, FL 32216

F 0908 Level of Harm - Minimal harm or potential for actual harm F - 145 degrees F. Temperature should coincide with manufacturer's label on machine. Check chemical level to make sure products are available. Refill or replace as necessary. Daily Warewash Procedures: Check Low Temps Sanitizer level-minimum of once a day. Acceptable range 50-100 ppm chlorine. (Copy obtained) Residents Affected - Many Reference: 4-204.115 Warewashing Machines, Temperature Measuring Devices. The requirement for the presence of a temperature measuring device in each tank of the warewashing machine is based on the importance of temperature in the sanitization step. In hot water machines, it is critical that minimum temperatures be met at the various cycles so that the cumulative effect of successively rising temperatures causes the surface of the item being washed to reach the required temperature for sanitization. When chemical sanitizers are used, specific minimum temperatures must be met because the effectiveness of chemical sanitizers is directly affected by the temperature of the solution. 4-501.11 Good Repair and Proper Adjustment. Proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed. Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk. F. Adequate cleaning and sanitization of dishes and utensils using a warewashing machine is directly dependent on the exposure time during the wash, rinse, and sanitizing cycles. Failure to meet manufacturer and Code requirements for cycle times could result in failure to clean and sanitize. For example, high temperature machines depend on the buildup of heat on the surface of dishes to accomplish sanitization. If the exposure time during any of the cycles is not met, the surface of the items may not reach the time-temperature parameter required for sanitization. Contact time is also important in warewashing machines that use a chemical sanitizer since the sanitizer must contact the items long enough for sanitization to occur. In addition, a chemical sanitizer will not sanitize a dirty dish; therefore, the cycle times during the wash and rinse phases are critical to sanitization. FDA Food Code 2022 Annex 3. Public Health Reasons/Administrative Guidelines Annex 3 - C. pages 165, 170-171. https://www.fda.gov/food/fda-food-code/food-code-2022. . 105682 Page 19 of 19