Health inspection·July 1, 2021

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few she did not know why Resident #57 was not wearing her Left hand splint. She indicated she should be wearing it. She noted that Resident #57 refused to wear it at times. However, Employee A revealed that she had not spoken with a nurse related to resident refusing to wear the splint. Also, she was unaware if Resident #57 was care planned with behaviors of refusing to wear the splint. On 6/30/2021 at 8:45 a.m. after the breakfast meal, Resident #57's Left hand was observed with the Left hand splint. Interview with the CNA Employee K, who was assigned to the resident, revealed that she applied the splint after breakfast this a.m. She was aware that the resident should have the brace on all day, and to be taken off only during meals. Employee K explained that, usually, the 7-3 shift staff would apply the splint after the breakfast meal. She also stated that the resident refused, at times, to wear the splint, but had not passed any of that information along to nursing in the past. Review of the medical record revealed Resident #57 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the advance directives found the resident had a Medical and Financial decision maker in place. Review of the admission diagnosis sheet revealed diagnoses to include: Left side Hemiplegia, Stiffness joints, Muscle weakness, Failure to thrive, Legal blindness, Glaucoma, Dementia, and Depression. Review of the Minimum Data Set (MDS) 5 day assessment dated [DATE] revealed: (Cognition/BIMS score 9 of 15); (ADL - Eating is extensive assist with one person, Dressing is total, Toilet use is extensive with one person, Personal Hygiene is total). Review of the progress notes dated, revealed: - 4/29/2021 15:00 - Left hand finger contractions noted causing fingers to press into palm. Palm cleansed skin noted to be moist, will continue to monitor for any change in hand condition. There was no documented notes from 2/1/2021 to current that reflected Resident 3 57 refused use of the Left hand splint, which was ordered on 6/8/2021. Also, there were no notes indicating use of the splint. Review of the current care plans with next review, date 8/12/2021, revealed the following: - Potential pain related to history of headaches, Left hand pain r/t contracture, has reported pain to L foot in the past but unable to elaborate and no hx/evidence of trauma, with interventions in place. - Has Activities of Daily Living self care deficit as evidenced by: Stroke, Hemiplegia, Blindness due to Glaucoma. Preferences for no male CNA for personal care, refuses to wear face mask with interventions to include: Left hand splint on in AM after care for remove every day and evening shift hours as tolerated. Review of the last Occupational Therapy discharge assessment, dated 6/21/2021, revealed Resident #57 reached her highest practicable level, which had been achieved with interventions to include: Splinting for the Left hand with patient and or caregiver training related to proper positioning in wheelchair and don/doff of the splint for the Left hand. On 6/30/2021 at 11:10 a.m. an interview with the Rehabilitation Director revealed that Resident #57 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105733 If continuation sheet Page 2 of 15 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 105733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was no longer on Physical Therapy (PT) and Occupational Therapy (OT) case load. She indicated that the resident was discharged from both PT/OT and had been on the restorative nursing program for use of Left hand splint and range of motion exercises. The Rehabilitation Director revealed that when the resident was on OT case load they were using a Left palm guard but the resident would refuse to wear it. She revealed that since then, there has been an order for Resident #57 to utilize a Left hand splint and as far as she knew, the resident had not refused to wear that device. Though Resident #57 had been off of PT/OT case load, the Rehabilitation Director was unaware that for the past couple of days (6/28/2021, and 6/29/2021), she was observed without the splint. She confirmed, in the electronic record, there were no documented notes within the past month of Resident #57 refusing to wear the Left hand splint. On 7/1/2021 at 9:38 a.m. an interview was completed with the A wing Unit Manager who confirmed, for those residents who require use of and utilize orthotics or splints for contracture prevention, they should be assisted with the device in the a.m. by CNAs with oversight from floor nurses. She revealed that if a resident were to refuse the orthotic or splint, it should be documented in the nurse notes and also confirmed that should the resident continually refuse this device, it should be care planned to show this behavior. On 7/1/2021 at 1:30 p.m. the Director of Nursing did not have a specific implementation of care plan interventions policy and procedure for review. 2. On 6/28/2021 at 9:39a.m., Resident #24 was observed in bed and his call bell was not within reach because the cord coming out of the call bell panel was only 3 inches in length. (Photographic evidence obtained). On 6/28/2021 at 10:35a.m., this surveyor tested the call bell in Resident #24's room and it was working. On 6/29/2021 at 8:08a.m., Resident #24 was observed in bed eating his breakfast and the call bell was observed to have a longer cord, however, the call bell was hanging down over the nightstand in front of the drawers and not within reach of Resident #24. A review of the facility's Policy and Procedure Nursing/Call Light/Answering with an effective date of October 2014 on 7/1/2021 revealed the following: 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 of the resident. Procedure: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105733 If continuation sheet Page 3 of 15 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 105733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641 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 0656 5. Make the resident as comfortable as possible. Position the call light within easy reach of the resident. Level of Harm - Minimal harm or potential for actual harm (Photographic evidence obtained). Residents Affected - Few Review of Resident #24's Care Plan (4/9/2021-4/11/2021) on 7/1/2021 found that Resident #24 was at risk for falls related to a history of cerebrovascular accident (CVA) with left hemiparesis, weakness and limited mobility, with interventions of place items in easy reach i.e. (for example) water, telephone, call lights. (Photographic evidence obtained). During an interview conducted on 6/28/2021 at 9:40a.m., Resident #24 confirmed that the call bell was not within his reach (cord length was 3 inches). Resident #24 stated, The pull cord is busted. During an interview conducted on 6/29/2021 at 8:11a.m., Resident #24 confirmed that the call bell was not within his reach. Resident #24 stated, No, I can't reach it. During an interview conducted on 6/29/2021 at 8:12a.m., Staff C confirmed that the call bell should be within resident #24's reach. Yes, it should be. During an interview conducted on 7/1/2021 at 9:45a.m., the Director of Nursing (DON) confirmed that call bells should be within resident's reach. The DON stated, Within reach. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105733 If continuation sheet Page 4 of 15 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 105733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews the facility failed to discontinue an indwelling catheter as prescribed by the physician and in a timely manner for a resident who did not have a diagnosis which supported the use of a catheter for one (#85) out of four residents sampled for urinary catheters. Findings included: An observation was conducted on 6/28/21 at 10:01 a.m., of Resident #85 lying in bed with a urinary drainage bag hanging from the bed frame. The tubing appeared to have straw-colored sediment in it. At 1:31 p.m., the resident stated that there were no problems with the catheter. A review of the Physician Orders for Resident #85 identified an order, dated 6/28/21 at 3:57 p.m., that instructed staff to Discontinue Foley Catheter, every evening shift for 1 day. The resident's Treatment Administration Record (TAR) indicated that the discontinuation of the Foley Catheter was scheduled and completed on 6/29/21. During a visit with Resident #85 on 6/30/21 at 11:32 a.m., the urinary catheter tubing contained yellow-gold liquid, as observed attached to a urinary drainage bag hanging from the bottom of the resident's wheelchair. The catheter tubing was observed lying on the floor under the resident's feet. The resident stated he did not know if staff had removed the catheter then had to replace it, don't know anything about that. At 11:40 a.m. on 6/30/21, Staff Member E, Licensed Practical Nurse (LPN), stated she did not get in report that the foley was supposed to be taken out and that she could find time to take it (catheter) out today. She confirmed that the urinary catheter tubing was on the floor and they need to adjust. Staff Member F, Unit Manager, stated, on 6/30/21 at 11:43 a.m., that he transcribed the order to discontinue Resident #85's Foley catheter yesterday and that Staff E had asked him about it and he had reviewed the progress notes and they did not reveal why the resident continued to have a urinary catheter. Staff F stated that the resident had come from the hospital with it (catheter) and that the resident did not have a diagnosis related to the continued use of the catheter. The Director of Nursing (DON) reviewed, on 6/30/21 at 12:25 p.m., Resident #85's TAR and spoke with Staff Member F, who confirmed that the resident continued to have a Foley urinary catheter. She confirmed that the checkmark above the nurse's initials on 6/29/21 of the TAR indicated that the discontinuation of the resident's Foley catheter had been completed. The DON acknowledged that if the catheter had been reinserted there would be a progress note indicating the reason for the reinsertion. She reviewed the Daily Skilled Note and confirmed that it did not indicate that the resident had a catheter. According to the admission Record, Resident #85 was admitted on [DATE]. The Electronic Medical Record (EMR) included diagnoses not limited to unspecified fracture of Right pubis subsequent encounter for fracture with routine healing, Type 2 Diabetes Mellitus with diabetic chronic kidney disease, atherosclerotic heart disease of native coronary artery without angina pectoris, and essential (primary) hypertension. The Admission/5-day Minimum Data Set (MDS), dated [DATE], for Resident #85 identified a Brief (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105733 If continuation sheet Page 5 of 15 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 105733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview of Mental Status score of 12, indicative of moderate cognitive impairment. The MDS indicated that the resident had an indwelling urinary catheter and no active diagnosis involving the Genitourinary system. On 6/30/21 at 1:28 p.m., the DON stated that the facility does attempt to discontinue Foley catheters within 72 hours (3 days) of the resident's admission if they do not have a diagnosis to support the ongoing use of a catheter. She stated the facility reviews admission during morning meetings and if they have a diagnosis for the Foley catheter. She reviewed Resident #85's EMR and confirmed that the resident did not have a diagnosis that supported the necessity of having a Foley catheter and that is should have been discontinued within the 72 hours of the resident's admission on [DATE]. A review of Resident #85's care plan indicated that resident was at risk for complications related to use of indwelling catheter. The policy Catheter and Drainage Bag Care, effective October 2014 and revised August 2017, identified the purpose of the policy was to minimize the risk of bladder infection, maintain skin integrity and to provide safe and proper care of the resident with an indwelling urinary catheter. The policy did instruct staff to secure drainage bag to the bed or wheelchair in such a manner that neither the bag nor the spigot touches the floor and when resident is in bed position drainage bag on side of bed opposite the doorway is possible. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105733 If continuation sheet Page 6 of 15 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 105733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure Pharmacy Recommendations were addressed by the provider for one (#73) of five residents sampled for the mandatory task of Unnecessary Medications. Findings included: On 6/29/21 at 4:06 p.m., Resident #73 was observed lying in bed with the head of the bed upright. The Electronic Medical Record (EMR) identified that the resident was admitted on [DATE]. The EMR included diagnoses not limited to anxiety disorder and depression. A review of the physician orders for Resident #73 found that the resident received the psychotropic medication, Alprazolam (Xanax) 0.25 milligram (mg) three times a day related to anxiety and Percocet 5-325 mg every (q) 4 hours as needed (prn) for non-acute pain. A Consultation Report from the Consultant Pharmacist, dated 5/19/21, indicated that Resident #73 received the benzodiazepine, Alprazolam three times a day for anxiety and there was no documentation of failure/contraindication to first-line therapies documented in the medical record. The Consultant recommended to please discontinue Alprazolam, Alprazolam tapering as indicated (e.g., decreasing the dose by no more than 25% or 10-12% in high risk residents, every 2 weeks) while concurrently monitoring for reemergence of target behaviors and/or withdrawal symptoms. The recommendation asked the physician to consider the alternative buspirone 5 mg twice daily increasing as tolerated 5 mg/day every 3 days, in divided doses until the desired maintenance dose was achieved. The rationale for the recommendation was for anxiety-based disorders, benzodiazepine's are considered second-line therapy and are generally reserved for short-term management. Older adults have a greater sensitivity to adverse effects of benzodiazepine's (e.g., drowsiness, confusion, falls). The Consultation Report was not signed by the physician and a handwritten note instructed to see note from Advanced Registered Nurse Practitioner (ARNP) 6/14. A Consultation Report, dated 6/7/21, indicated that the Consultant Pharmacist identified that Resident #73 had an as needed (prn) order for Percocet 5-325 mg every (q) 4 hours (hrs) prn for pain since at least 10/24/2020. The pharmacist recommended to reduce prn analgesic therapy with the end goal of discontinuation or until the lowest effective dose was achieved. The report instructed that if this routine analgesic is to continue, it is recommended that a) the prescriber document an assessment of risk versus benefit indicating that it continues to be a valid therapeutic intervention for this individual; and b) the facility interdisciplinary team ensures ongoing monitoring for effectiveness and adverse effects. The report asked the physician to indicate by a notation if they accepted the recommendation as written, accepted the recommendation with modifications, or declined the recommendations with a rationale. The report was not signed by the physician and a handwritten note instructed to see note from ARNP 6/14. On 6/30/21 at 12:25 p.m., the Director of Nursing (DON) stated that the facility does not have the physician sign the Pharmacist recommendations, didn't you see the note to see the ARNP note, and was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105733 If continuation sheet Page 7 of 15 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 105733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few noncommittal as to whether the pharmacist had to review the ARNP notes to locate if the physician had reviewed the recommendations, she stated we can start having them sign it. The Advanced Practitioner Registered Nurse (APRN) Evaluation, dated 6/14/21, indicated that Resident #73 was in no acute distress and had no complaints. The Assessment and Plan of the Evaluation indicated that on 6/14 the APRN renewed prescriptions for Percocet and Xanax and discussed case (with) nursing. The evaluation note did not indicate that APRN had reviewed the Consultant Pharmacist recommendations from May and June 2021. The Consultant Pharmacist stated, on 7/1/21 at 8:58 a.m., that the expectation was that the physician addressed the recommendations in the shortest time possible. He stated that he believed the regulation was that the physician had to address the actual recommendations and had no issues with the facility getting a recommendation. On 7/1/21 at 9:41 a.m., the APRN confirmed he did address the Pharmacist recommendations and did sign the recommendations. He stated they just faxed a bunch of them, maybe 30, which is rare, usually they put them in my folder. The APRN indicated that the facilty would put the recommendations in a folder on the Rehabilitation unit, he would sign them, and then would put them in another folder to be filed. He confirmed he did not write See note from ARNP 6/14 on either May or June 2021's pharmacy recommendation, he stated if he had seen them he would have signed it and taken the 30 seconds to write a reason for his rejection of the recommendation or that Psychology was following the resident if it was regarding a psychotropic medication. He stated that the case discussion with nursing, as noted in his evaluation on 6/14/21, was general: how was the resident, any issues going on then would speak with the resident. The APRN reiterated that he would not write see note from ARNP on the pharmacy recommendations. The Psychiatry APRN progress note, dated 6/8/21, indicated that Resident #73 was receiving the psychotropic medications: Cymbalta, Xanax, and Trazodone. The recommendations/plan indicated there were no changes and to monitor and follow up as needed. The note indicated that the Psychiatry APRN had met with the Interdisciplinary treatment team to evaluate safety and efficacy of psychotropic medications but did not identify that the pharmacy recommendation for discontinuing Alprazolam and prescribing Buspirone was discussed. The policy, Medication Regimen Review, effective 12/01/07 and revised 11/28/16, 3/20/20, and 6/11/21, indicated that the For those issues that require Physician/Prescriber intervention, Facility should encourage Physician/Prescriber to either accept and act upon the recommendations contained within the Medication Regimen Review (MRR), or reject all or some of the recommendations contained in the MRR an provide and explanation as to why the recommendation was rejected. The MRR procedures indicated that The attending physician should document in the residents' health record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If the attending physician has decided to make no change in the medication, the attending physician should document the rationale in the residents' health record. Procedure 11 of the policy identified that the attending physician should address the consultant pharmacist's recommendation no later that their next scheduled visit to the facility to assess the resident either 30 or 60 days per applicable regulation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105733 If continuation sheet Page 8 of 15 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 105733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641 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%. Twenty-nine medication administration opportunities were observed, and two errors were identified for two (#97 and #204) of seven residents observed. These errors constituted a 6.8% medication error rate. Residents Affected - Few Findings included: 1. On 6/29/21 at 8:07 a.m., an observation of medication administration with Staff Member G, Licensed Practical Nurse (LPN), was conducted with Resident #97. Staff G, LPN was observed administering the following medications: - Vitamin C 500 milligram (mg) oral tablet - Aspirin 81 mg chewable tablet - Furosemide 20 mg oral tablet - Multivitamin oral tablet - Acidophilus oral capsule A review of the physician orders indicated that Resident #97 was ordered to receive a Multivitamin with mineral - one capsule by mouth one time a day for skin impairment. 2. On 6/29/21 at 11:55 a.m., an observation of medication administration with Staff Member G, Licensed Practical Nurse (LPN), was conducted with Resident #204. Staff G, LPN was observed administering the following medications: - Novolog 100 unit/milliliter (mL) Flex Pen - 4 units subcutaneously Staff G was observed, prior to the administration, place an insulin pen needle on the Flex Pen, dial the dose selector to 2 units and depress the selector while holding the pen parallel to the floor and ejecting insulin into the sharp box attached to the medication cart. The staff member dialed the selector to 4 units and injected insulin into Resident #204. Immediately following the administration, she stated they (the facility) told her during orientation that she had to prime the Flex pen and it was to get the insulin into the needle and remove the air from the pen. She confirmed that by holding the pen parallel to the floor the air bubble would have been in the middle of the pen and not ejected from the pen when primed. On 8:58 a.m. on 7/1/21, the Consultant Pharmacist stated that staff should follow physician orders and Insulin pens should be primed per manufacturer. The Director of Nursing stated, on 7/1/21 at 10:07 a.m., the facility was looking at getting rid of insulin pens and confirmed that the air bubble would have been in the middle of the insulin pen when the staff member primed the pen while holding it parallel to the floor. The facility reported not having a policy related to following physician orders. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105733 If continuation sheet Page 9 of 15 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 105733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641 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 According to the manufacturers' medication insert, (https://www.novomedlink.com/content/dam/novonordisk/novomedlink/resources/generaldocuments/NovoLog%20FlexPen% an airshot should be given before each injection as small amounts of air may collect in the cartridge during normal use. The instructions indicated that to avoid injecting air and to ensure proper dosing: Residents Affected - Few - Turn the dose selector to select 2 units; - Hold your NovoLog Flex Pen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. - Keep the needle pointing upwards, press the push-button all the way in. The dose selector returns to 0 (zero). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105733 If continuation sheet Page 10 of 15 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 105733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to ensure drugs and biologicals were stored & labeled with currently accepted professional principles regarding 1. Narcotic containers not permanently affixed in 2 (A Wing & C Wing) of 2 refrigerators 2. Insulin pens and eye drops not labeled with Expiration dates or expired in 2 of 3 medication carts (A-1 and C-5) & and 3. Narcotic count not reconciled in one (A-1) of 2 medication refrigerators. Findings included: 1. On [DATE] at 2:46 p.m., an observation was conducted with Staff J, LPN, of the A-wing medication room. The observation revealed a gray metal locked box inside the medication refrigerator. The locked box was unattached to the refrigerator. She stated that narcotics were kept in the locked box. She confirmed that she could walk out of the room with the box as it was not permanently affixed to the refrigerator. Staff J stated the facility was trying to glue the box to the shelf but she told them it was not going to work. An observation was conducted with the DON, on [DATE] at 3:24 p.m., of the C-wing medication room. The medication refrigerator was not locked. The gray narcotic box was affixed to a removable glass shelf. The DON confirmed the findings and stated the box was double locked as the box and the room were locked. She confirmed that the glass shelf could be removed from the refrigerator. 2. On [DATE] at 10:49 a.m., an observation was conducted with Staff Member G, LPN, of the C-4 medication cart. The observation revealed an unopened Levemir insulin pen that was labeled to refrigerate until opened. Staff G confirmed the findings and stated that the pen should have been refrigerated as labeled. On [DATE] at 1:54 p.m., an observation was conducted with Staff Member I, LPN, of the medication cart C-5. The observation revealed a Humalog 100 unit/mL insulin pen was opened and undated. Staff I confirmed that the pen was opened and had been received by the facility on [DATE]. Photographic evidence was obtained. A Novolog Insulin Flexpen was observed with other insulin pens. The Flexpen was opened, undated with an open date, labeled with an expiration date of [DATE]. The observation revealed an opened bottle of Latanoprost 0.005% eye drops. The bottle was not dated with an open date. The pharmacy label indicated that the drops were to be discarded after 42 days. The label indicated that the facility had received the medication on [DATE]. 3. On [DATE] at 11:00 a.m., an observation was conducted with Staff Member H, Licensed Practical Nurse (LPN), of the A-1 medication cart. The staff member identified that the facility counts the narcotics twice a day, before and after the shift. She reported that there were 17 blister cards in the cart and one bottle in the medication refrigerator. The nurse unlocked the narcotic box in the refrigerator and was unable to locate the bottle of Lorazepam that the Controlled Medication Utilization Record, located in the Controlled Substance binder on the A-1 cart, indicated that on [DATE] the bottle contained 11.25 milliliters (mL). When she was unable to locate the bottle she stated, oh the Director of Nursing (DON) did something with it yesterday. Staff H confirmed that she had not verified that the bottle of Lorazepam was in the refrigerator that morning, she stated that normally does but this morning it was hurry hurry go go. Immediately following the observation, the DON was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105733 If continuation sheet Page 11 of 15 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 105733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641 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 interviewed and reported that someone had brought her the bottle this morning due to the label being unreadable. The DON stated that she should have removed the Utilization Record from the controlled substance binder, used by staff to count/track the scheduled medications. The DON stated that Staff Member F, Unit Manager (UM), should have informed Staff Member H that the bottle of Lorazepam had been removed from the refrigerator and that the Controlled Medication Utilization Record should have been removed from the binder. On [DATE] at 3:02 p.m., Staff Member F stated that the Corporate nurse had given him the bottle of Lorazepam and that the normal procedure would have been to give it the DON so she could waste the medication. The staff member reported that the medication and the Utilization Record were to kept together until the medication was wasted. Staff F stated staff were to subtract the medication administered from the count record and that the record should have indicated that the corporate nurse had taken the Lorazepam out of rotation. He stated that he thought Staff H had been there when the medication was removed. The Controlled Medication Utilization Record indicated that on [DATE] the bottle of Lorazepam contained 11.25 milliliters. The policy, Inventory Control of Controlled Substances, effective [DATE] and revised [DATE] and [DATE], indicated the following: - Facility should ensure that the incoming and outgoing nurses count all Schedule II controlled substances and other medications with a risk of abuse or diversion at the change of each shift or at least once daily and document the results on the Controlled Substance Count Verification/Shift Count Sheet. - - Reconcile the total number of controlled medications on hand, add newly received medications to the inventory, and remove medications that are completed or discontinued from the inventory, pursuant to the Controlled Substance Verification/Shift Count Sheet. 4. The policy Storage and Expiration of Medications, Biological's, Syringes, and Needles, effective [DATE] and revised [DATE], [DATE], indicated that the policy sets the procedures relating to the storage and expiration dates of medications, biological's, syringes, and needles. The policy identified the following: - Facility should ensure that medications and biological's that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier. - 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 medication container when the medication has a shortened expiration date once opened. -- Facility staff may record the calculated expiration date based on date opened on the medication container. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105733 If continuation sheet Page 12 of 15 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 105733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on observation, record review, interviews, policy review, and review of the facility's Plan of Correction, the facility failed to ensure that it had a functioning Quality Assurance Committee. The facility was actively involved in the effective creation, implementation and monitoring of the Plan of Correction for deficient practice identified during a recertification survey and complaint investigation conducted on 6/28/2021 through 7/1/2021; F759 and F761 were cited. On 09/07/2021 deficient practice was identified related to F759 and F761. The facility had developed a Plan of Correction with a completion date 07/31/2021. Findings included: 1). The facility developed a Plan of Correction related to on-going compliance with 1. medication error rate was less than 5.00% and drugs and topical biologicals were stored and labeled with currently accepted professional principles. 2). The facility developed a plan of correction that included: Education on the 5 rights of medication administration. Randomly audit med pass 2 times a week for 2 months and then 1 time a week for 1 month. The results of the audits will be reported to the Quality Assurance Performance Improvement Program (QAPI) monthly for 3 months. 3). During the revisit survey on 09/07/2021, the facility failed to ensure the medication error rate was less than 5.00%; twenty-six medication administration opportunities were observed, and five errors were identified for two residents (# 2 and 5) of eight residents observed. These errors constituted a 19.23% medication error rate. 4). Review of the facility policy title 'General Dose Preparation and Medication Administration' dated 12/01/07 Applicability: This policy 6.0 sets forth the procedures relating to general dose preparation and medication administration. Facility staff should refer to the facility policy regarding medication administration and should comply with applicable law and the State Operations Manual when administering medications. 4). Prior to the administration of medication, facility staff should take all measures required by facility policy and applicable law, including but not limited to the following: Facility staff should: verify each time a medication is administered that is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time. 5). On 9/7/2021 at 8:35 a.m. an observation of medication administration was conducted alongside Staff Member D, Registered Nurse (RN) for Resident#2. After Staff D prepared eight of the medications she stated, I can't find the ordered folic acid. She was overheard asking a staff member for the medication. Staff D returned to the medication cart and said they only had Folic Acid in 400 microgram (mcg) tablets. She stated, I'll just give two of the 400 mcg that will be 800 mcg (0.8 mg) and write a note. Staff D administered the oral medications to the resident, and then provided the Symbicort inhaler. Medication reconciliation revealed Physician order date 12/14/2020 read for Folic Acid tablet 1 mg for folic deficiency and Symbicort aerosol 160-4.5 MCG 2 puffs inhale orally two times a day for Chronic Obstructive Pulmonary Disease (COPD) Use with spacer chamber dated on 12/12/2021. A spacer chamber was not used when administered. 6). At 2:25 p.m. an interview was conducted with the Director of Nursing (DON) she confirmed that if the correct dosage of medication was not available it should not be substituted. Additionally, the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105733 If continuation sheet Page 13 of 15 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 105733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few ordering Physician would need to be notified. She said she would investigate why the Symbicort was not administered with the ordered spacer chamber. She stated, she is an agency nurse that has been here for a while now. 7). At 4:25 p.m. on 9/7/2021 a medication observation was conducted alongside Staff Member E, Licensed Practical Nurse (LPN) for Resident #5. Staff E said she was unable to find the ASA [aspirin] EC [enteric coated] 81 milligrams (mg). She continued to prepare the medications then stated the Remeron 7.5 mg is missing. The resident was administered medications and the ASA EC 81 mg and Remeron 7.5 mg were omitted. The DON stopped by the medication cart and asked if something was missing. Staff E told her about the missing ASA and Remeron. The DON said the staff member that works in central supply just left the facility. Stated she is driving to the pharmacy. Medication reconciliation revealed physician order date 2/22/20 for Lamotrigine tablet 200 mg give 1 tablet by mouth one time a day for mood regulation - give right after dinner. The facility had identified that the dinner meal is served between 5:00 and 5:30 p.m. At 4:33 p.m. on 9/7/2021 during an interview Staff E stated, I did not see that it said to give after dinner. 8). During the revisit survey on 09/07/2021 the facility failed to ensure drugs and biologicals were stored and labeled in accordance with acceptable professional practices as evidenced by: 1) topical biologicals stored with oral medications in two ( A-2 and A-1) of three medication carts observed; and 2) medications not dated when opened and not stored beyond the expiration date in three (A-2, A1 and C-1) of three medication carts observed. 9). The facility developed a plan of correction that included: Educated licensed staff un-opened insulin pens should be refrigerated until opening for use and the need to date eye drops and insulin when opened and monitor for expiration. Medication cart audits to be conducted 2 times a week for 1 month and weekly thereafter. The results will be reported to the QAPI monthly for 3 months. 10). On 9/7/2021 at 11:30 a.m. medication cart A-2 was observed with Staff Member F, Licensed Practical Nurse (LPN) The cart revealed a small plastic bag that contained a tube of antibiotic eye ointment. The packaging did not contain a date when it was first opened. Additionally, a small brown glass bottle read 'nitroglycerin sublingual tablets.' The seal on the bottle was no longer intact and it did not have a pharmacy label. Staff F confirmed the bottle had been opened and said she did not know who it had belonged to. Additional observations revealed an insulin Novolog pen with an expiration date of 9/3/2021; a box that contained Levemir insulin revealed the pharmacy label had been changed - where it had read 20 units was crossed off with red pen and manually written was '10.' During an interview conducted as part of the observation, Staff F stated, we don't have pharmacy stickers on this unit to put on the label. The third drawer of the medication cart revealed stored topical biologicals stored next to oral medications; two bags of antibiotic topical power indicating to apply under bilateral breasts were observed, including a roll-on pain reliever and a tube of topical gel indicated for pain. Staff F stated I keep them in the cart. so, I know were there at. I know they shouldn't be there. Photographic evidence was obtained. 11). At 12:10 p.m. on 9/7/2021 an observation was conducted alongside Staff Member B, Registered Nurse of the medication cart A-1. The observation revealed an insulin vial that had been opened, without out a date when first opened, a box Santyl ointment, two boxes labeled Combivent inhaler without an open on date, a bottle of opened eye drops without an opened-on date, and a Novolog insulin pen with an expiration date of 8/29/2021. Photographic evidence was obtained. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105733 If continuation sheet Page 14 of 15 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 105733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/01/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 12). At 12:35 p.m. on 9/7/2021 medication cart C-1 was observed alongside Staff Member G, Registered Nurse. The cart revealed three Levemir insulin pens; one pen had been opened and it did not contain an opened-on date, and the other two insulin pens, which had not been opened contained pharmacy directions that read refrigerate until opened. Additionally, two separate bags of prefilled syringes for Aplisol 0.1 milliliter were identified with directions to keep refrigerated, an opened box of calcium spray which did not contain an opened-on date, and an opened box that contained a Breo inhaler which did not contain an opened-on date. Staff G confirmed the findings of the observations. 13). At 1:30 p.m. on 9/7/2021 an interview was conducted with the Director of Nursing (DON) she said that the unit manager usually will check the medication carts. But she had worked over the weekend and didn't look at carts on Monday. The DON said the normal process for auditing the carts is primarily the night shift. But we have had some irregularity with staffing and are using agency routinely now. She confirmed that the eleven to seven shift nurses are supposed to be auditing the medication carts. She confirmed it is her expectation that the carts are free from expired medications. 14). On 09/07/2021 at 5:20 p.m. an interview was conducted the Risk Manager / Assistant Director of Nursing. She said the last Quality Assurance Meeting was conducted in July 2021. She stated, no meeting was conducted in August 2021. She said she has been ill at the time. The Risk Manager said that she is the one responsible for scheduling the month meetings. She said in July 2021 they had a meeting about the Plan of Correction, and all department heads including the Medical Director were involved in the process. The Risk Manager said she was responsible for the Plan of Correction and spoke about performing the audits on the medication storage. She confirmed education was provided on medication storage, labeling and training for insulin pens, stating they must be refrigerated until opened for use, eye drops, and insulin are to be dated when opened, and to monitor for expiration dates. She stated we will restart the audits again. Regroup and start the process again. She stated they had spoken about the medication error rate and how they had performed competencies. Then she stated but we have different nurses now. We use agency nurses. We will have to restart the audits. 15). A review of the facility policy QAPI -Nursing, Social Services, Risk Management effective date: 02/20/2018 revision Date: May 2018. Read Each center must develop, implement, maintain and effective comprehensive, data driven Quality Assurance and Performance Improvement Program that focuses on indicator or the outcomes of care and quality of life. QAPI identifies opportunities for improvement, addresses gaps in system, and involves performance improvement plans with monitoring of interventions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105733 If continuation sheet Page 15 of 15