Health inspection·March 30, 2023

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 03/29/2023 at 1:44 p.m. an interview was conducted with Minimum Data Set Coordinator. She confirmed Resident #24's MDS was omitted of the diagnosis of anxiety, bipolar, and psychiatric disorders. The facility denied having a procedure or policy in place for the accuracy of the Minimum Data Sheet. Minimum Data Set The Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. [DATE]. Minimum Data Set 3.0 Public Reports - accessed at https://www.cms.gov > Computer-Data-and-Systems on 03/30/2023. Event ID: Facility ID: 105733 If continuation sheet Page 2 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/30/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure that two (#24 and #66) out of two sampled residents had a Preadmission Screening and Resident Review (PASRR) that reflected an accurate screen decision-making for mental illness or suspected mental illness. Findings included: 1. On 03/28/2023 at 9:49 a.m. Resident # 24 was observed from her door way sitting up in her bed eating her breakfast. She looked at the open door and stated outloud help me. Resident #24 waved her hand that gestured to come here, and as she was approached she stated move me over it hurts to sit on my bottom. A nurse was in the hallway and was informed of the resident need, he stated she will say that over and over, she does it all the time. The nurse and a certified nursing assistant assisted the resident. Resident #24 thanked staff over and over again, as she stated she was no longer in pain. Medical record review of the admission Record form revealed Resident #24 had resided at the facility for over five years and is geriatric in age. The form contained diagnosis information that listed schizoaffecive disorder, bipolar type and major depressive disorder. Review of Psychiatric Nurse Practitioner Progress note dated 04/06/2022 revealed Problem (Prob.): Her condition today does not allow (Resident #24 name) to describe her symptoms. EXAM: (resident #24 name) condition today does not allow cognition to be formally tested. DIAGNOSES: The following Diagnoses are based on currently available information and may change as additional information becomes available: Unspecified dementia without behavioral disturbance, Psychotic disorder with delusions due to known physiological condition. Review of Preadmission Screening and Resident Review (PASRR) dated 02/19/2018 revealed Section I: PASRR Screen Decision-Making A. MI or suspected MI (check all that apply) areas checked: Anxiety Disorder, and other: Depression. Findings are based on: Documented History and Medications. Areas that were not checked as medical record reflected included Bipolar Disorder, Psychotic Disorder and Schizoaffective disorder. On 03/29/23 at 1:20 p.m. and interview was conducted with the Social Worker Assistant (SWA) and Social Worker Director (SWD). They revealed they were unaware if a resident is diagnosed after admission with a new serious mental illness (SMI) the current PASRR screen would reviewed for accuracy. The SWD stated I would need to look at the facility policy. On 03/29/2023 at 1:30 p.m. an interview was conducted with the Regional Director of Clinical Services who confirmed she was aware of the focus on PASRR accuracy, and said the company has already started to look into them. At 2:00 p.m. the Regional Director of Clinical Services said the facility did not have a policy or procedure in place for PASRR. She stated we follow what is regulated by the state. 2. Review of Resident #66's medical record was conducted. The admission record revealed an initial (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105733 If continuation sheet Page 3 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/30/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some admission date of 12/28/22 and diagnoses that included, dementia and anxiety disorder. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed active diagnoses that included non-Alzheimer's dementia and anxiety disorder. Review of active physician orders revealed Resident #66 was prescribed Alprazolam for anxiety/agitation two times a day, Remeron at bedtime for depression, and Mirtazapine at bedtime for depression. The PASRR Level I document for Resident #66's admission, dated 11/25/22, had no diagnoses documented in Section I, all questions in Section II were documented as no, and section IV was documented as No diagnosis or suspicion of SMI (serious mental illness) or ID (intellectual disability) indicated. Level II PASRR evaluation not required. There were no additional PASARR documents in Resident #66's medical record. Interview with the facility Administrator (NHA) on 3/30/23 at 10:04 a.m. confirmed there was no facility policy related PASRR and no procedure in place for ensuring PASRRs were update. She reported that with the changes of who was qualified to complete PASRRs, they had a break in their system and need for updates wasn't getting triggered since their Social Services staff did not have the required qualifications to complete them. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105733 If continuation sheet Page 4 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/30/2023 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure identification of need, and development and implementation of an individualized one to one activities program to support the physical, mental, and psychosocial well-being for two residents diagnosed with dementia (Resident #108 and Resident #66) out of two sampled residents. Residents Affected - Some Findings included: 1. Multiple observations of Resident #108 were conducted. She was not observed engaged in activity programming during any observations. On 03/27/23 from 12:15 p.m. to 12:45 p.m. Resident #108 was observed in her wheelchair out of her room on her unit (C wing) verbally agitated and calling out for help and asking for her son. Initially she was in front of the nurse's station and then was moved by Staff C, Certified Nursing Assistant (CNA) and placed in hallway in front of her room with a tray table in front of her where she continued to call out and exhibit verbal agitation. Multiple staff were in the area but nobody addressed or engaged her. On 03/28/23 beginning at 9:30 a.m., Resident #108 was observed in her wheelchair alone at a table in the resident lounge area on her unit (C wing) with breakfast tray. The television was on without sound in the room. There was a hospice staff member present at another table in the room documenting, no other staff or residents were in the room. No staff were observed engaging with Resident #108, she had finished eating and was sitting with her meal ticket in her hand looking at it. Eventually a CNA removed her breakfast tray and she was left there just sitting alone at the table until 9:50 a.m. when a nurse entered the room and wheeled the resident closer to the television and then left the area. Resident #108 was observed sitting where the nurse left her, not attending to the television, and with no other stimulation or materials to engage her. She began pulling and picking at her clothes and the arm of her chair and then at 10:05 a.m. she was observed attempting to get out of her wheelchair and onto the couch. A therapy department staff member was passing by the lounge as Resident #108 was attempting to get out of her wheelchair, intervened and re-directed her back into the wheelchair and wheeled her out into the hall and placed her in front of the nurse's station and left the area. Other staff were in the area and at the nurse's station but nobody attended to or engaged the resident. At 10:08 a.m. the resident was observed fiddling with her shirt. At 10:20 a.m. a therapist arrived and wheeled her off the unit for a therapy session. On 03/28/23 at 2:00 p.m. Resident #108 was observed alone in her room. She did not have a roommate. Personal belongings were not observed in the room. She was seated in her wheelchair and the television was on without sound. On 03/29/23 Resident #108 was observed in her wheelchair out of her room on the unit throughout the morning, not engaged in any activity programming. On 03/29/23 at 12:40 p.m. Resident #108 was observed seated in her wheelchair asleep in front of the nurse's station. On 03/29/23 at 3:09 p.m. Resident #108 was observed in her room seated in her wheelchair with tray table in front of her. On the tabletop was television remote, activities daily pamphlet, and a cup with hydration. The television was off and nobody was in the room with her. The resident was calling out and exhibiting verbal agitation. On 03/30/23 at 9:20 a.m. Resident #108 was observed eating breakfast in bed in her room. Nobody was present with her in the room. The television was off. She was engageable and confused and said, I don't know what's going on. There was an activities calendar posted on the wall across the room by the door (Resident #108 was in the bed by the window) and there were some magazines on the dresser across the room from her bed out of her reach. An interview was conducted with Resident #108's nurse, Staff D, Licensed Practical Nurse (LPN) on 03/29/23 at 9:46 a.m. He reported the resident was significantly confused and had periods of agitation and and was hard to redirect in those times, but that generally she was calm and engageable. He (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105733 If continuation sheet Page 5 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/30/2023 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 0679 did not have input about activities programming. Level of Harm - Minimal harm or potential for actual harm An interview was conducted with Staff C, CNA on 03/30/23 at 9:23 a.m. She reported Resident #108 did not attend activities because she didn't like it. She stated sometimes she would put the resident in the hallway so she could see what was going on. Residents Affected - Some Review of Resident #108's medical record revealed an admission record with admission date of 02/21/23 and diagnoses that included dementia with agitation, major depressive disorder, and cognitive communication deficit. The Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 7 which meant the resident was moderately cognitively impaired. Section F, Preferences for Customary Routines and Activities, in the MDS revealed information about activity preferences had been gathered from the resident. Preferences revealed it was not very important to the resident to have books, newspapers, and magazines to read, it was somewhat important to the resident to listen to music, be around animals, do things with groups of people, engage in favorite activities, go outdoors, and participate in religious services. Section F revealed it was very important to the resident to keep up with the news. Section G of the MDS revealed Resident #108 was dependent on staff for transfers and mobility and required extensive assist for Activities of Daily Living (ADL) except for eating which was documented as requiring supervision. There was no focus area for activities. An interview was conducted with the facility Activities Director on 03/29/23 at 4:31 p.m. She reported her department was fully staffed. Regarding Resident #108 she stated that a staff member visited her each morning to invite her to activity and either she refused or if a group was attempted, she was disruptive to others. Regarding 1:1 activity program, she stated that residents who were assigned 1:1 were seen twice a week, but that Resident #108 was not on a 1:1 program. She stated that since it had been brought to her attention she would put Resident #108 on a 1:1 activities program. A follow up interview was conducted with the Activities Director on 03/30/23 at 9:40 a.m. She confirmed the only documentation for activities participation for Resident #108 was for self-directed activity which she stated meant watching television in the room or using materials on her own in her room. She reported she had updated Resident #108's care plan to include 1:1 activity program 3 times a week, and had initiated education with Activities staff to ensure they were documenting properly. Regarding process for identifying need for 1:1 programming for a resident she responded, if they aren't coming out of their room or not able to come out of their room for medical issues, I'll put them on 1:1, then if things change I may take them off. Review of Resident #108's care plan following interview with Activities Director revealed focus area initiated on 03/30/23 for activities: [Resident #108] is comfortable in room setting, 1:1 visit will be provided or independent activity in comfort of own room. Conversation, crafts, reading, Therapeutic touch, hand massage, TV, family visit encourage to attend group programs .[Resident #108] will be accepting of 1:1 visits with Life Enrichment staff and engage actively for a minimum of 15 minutes 3 times per week through next review . 2. Multiple observations of Resident #66 were conducted. She was not observed engaged in activity programming during any observations. On 03/27/23 from 9:07 a.m. to 9:35 a.m. the resident was observed in bed crying loudly, exhibiting distress. At 12:10 p.m. on 03/27/23 the resident was observed in bed asleep. On 03/28/23 the resident was observed in bed throughout the morning crying out loudly, exhibiting distress. Her door was maintained closed for periods of that time. No attempts to engage the resident in activity or redirection were observed from any staff members. On 3/28/23 at 1:59 p.m. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105733 If continuation sheet Page 6 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/30/2023 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #66 was observed in bed asleep. Her roommate was in the room watching television and the door was open. On 03/29/23 at 9:04 a.m. Resident #66 was observed in bed, was not crying out. On 03/29/23 at 9:46 a.m. the resident was observed in bed crying out, exhibiting distress. Her nurse, Staff D, LPN was at bedside administering medications, he spoke to her in a calm tone and offered and provided beverage, she calmed during the interaction and the began crying again. On 03/29/23 from 9:46 a.m. to 11:53 a.m. Resident #66 was in bed crying, exhibiting distress. At 12:40 p.m. and 3:05 p.m. on 12/29/23 she was observed asleep in bed. On 03/30/23 at 9:15 a.m. Resident #66 was again in bed crying out. There was an Activities bulletin out of her reach on the dresser, printed in English. An interview was conducted with Staff C, CNA on 03/27/23 at 9:35 a.m. She confirmed the resident was Spanish speaking but also spoke and understood some English. She stated the crying behavior was typical most mornings and said it was usually because she missed her family, said that was why she was crying that morning. Staff C confirmed that she herself spoke Spanish and generally communicated with the resident in Spanish. She did not have any input about activities program. An interview was conducted with Resident #66's nurse Staff D, LPN on 03/29/23 9:46 a.m. He confirmed communication with the resident was complicated by her dementia diagnosis and language, but she did understand and speak some English. He confirmed he had cared for her since her admission to the facility and she had always demonstrated the crying agitated behavior and often it was because she wanted her family or wanted company. He did not have any input about activities engagement, but stated she tended to become calm when someone was with her, that she responded well to calm approach, holding her hand, providing comfort, but that the floor staff did not have time to just sit with her. Review of Resident #66's medical record revealed an admission record with admission date of 12/28/22 and diagnoses that included dementia, anxiety disorder, and hemiplegia (paralysis of one side of the body). The MDS assessment dated [DATE] revealed a BIMS score of 99 which meant the resident was not able to complete the interview. Section C revealed the resident had short term and long term memory problems and moderately impaired cognitive skills for daily decision making. Section D revealed the resident had experienced and exhibited feeling down, depressed, or hopeless. Section F revealed information about activity preferences was obtained from family members. Preferences revealed it was somewhat important to the resident to listen to music, be around animals, go outdoors, participate in religious activities, and keep up with the news. Doing things with groups of people was documented as not very important to the resident. Doing favorite activities was documented as very important to the resident. Section G of the MDS revealed Resident #66 required extensive assist for transfers, mobility, and ADL performance. The care plan revealed a focus are for activities initiated 01/06/23, revised 03/30/23: [Resident #66] is alert with confusion prefers spending leisure time in bed and watches TV family visit often. [Resident #66] primary language is Spanish and can understand English 1:1 visit will be offered 3x a week and encourage to attend group programs of interest .Provide Spanish translated materials for in room activities. Interviews were conducted with the Activities Director on 03/29/23 at 4:31 p.m. and 03/30/23 at 9:40 a.m. Regarding Resident #66 she reported a staff member visited her every morning, provided the daily activity bulletin, and invited her to activities but either she refused or if group was attempted she was disruptive to others. She stated the staff put on Spanish channels on her television for her. She stated Resident #66 wasn't on a 1:1 program because she had a lot of family involvement and they visited often. She confirmed family visits didn't take the place of facility's responsibility for providing for activity program to support resident engagement. She confirmed there was no activities documentation for Resident #66 aside for self-directed activity which she stated meant watching television. She reported she would be putting Resident #66 on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105733 If continuation sheet Page 7 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/30/2023 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 1:1 program now that it had been brought to her attention. Care plan updated 03/30/23 revealed 1:1 program. Facility policy titled Life Enrichment Manual dated 11/2022 revealed: Life enrichment programs are developed and implemented to meet the individualized physical, mental, Spiritual, and psychosocial/emotional needs of the guest/resident as well as promoting self expression and choice. Activities refer to any endeavor, other than routine activities of daily living, in which a guest/resident participates that enhances his/her sense of well-being and that promotes or enhances physical, cognitive, and emotional health. Life enrichment programs are designed and adapted to be person-appropriate and to promote self-esteem, pleasure, comfort, education, creativity, success, and independence. Procedure: 1. Initiate a Life Enrichment evaluation and plan of care within five (5) business days of admission. 4. Inform the nursing team of the guest's/resident's life enrichment interests and request assistance with transferring guest/resident to activities as indicated. 5. Document guest/resident participation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105733 If continuation sheet Page 8 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/30/2023 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 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and medical record review, the facility failed to ensure one (#90) out of two residents sampled for communication and sensory were provided care and treatment in timely manner for a hearing deficit. Residents Affected - Few Findings included: On 03/27/2023 at 9:50 a.m. Resident #90 was observed in her bedroom and was receptive to an interview. She appeared comfortable as she talked about her short term rehabilitation that extended into long term care. During the interview process Resident #90 asked the surveyor to talk louder on multiple occasions indicating a hearing deficit. She stated I'm very hard of hearing. She went on to say the facility had sent her out to an audiologist appointment last month, but he did nothing. He didn't even look into my ears. He told me my hearing loss could be from something else. Resident #90 repeated he did nothing for me. Medical record review of the admission Record form for Resident #90 diagnosis list did not reflect a deficit in hearing. Review of Resident #90 progress notes dated: 02/15/2023 at 11:56 a.m. revealed Communication with Physician Note Text: call to primary care provided (PCP) to report that resident states she had difficulty hearing out of her left ear. Resident also report a sharp pain in the ear from time to time. Upon examination with otoscope it was noted that there was some ear wax in the left ear cannel, no redness or swelling noted at time of examination. Will have resident seen by audiologist to assess. Progress notes dated 02/16/2023 at 11:21 a.m. revealed Has audiology appointment with [name of audiologist] on Feb. 21, 2023 @1:00 p.m. transport wheelchair Transport resident aware of appointment and transport with no concerns at this time, Signed by Staff member B, Certified Clinical Specialist. Further review of medical record revealed an omission of the audiology appointment findings for 02/21/2023 that Resident #90 stated she had attended. On 03/28/2023 at 3:00 p.m. an interview was conducted with the Social Worker Assistant (SWA) and was asked for assistance in locating Resident #90 audiology report findings from her appointment on 02/21/2023. The SWA stated I'll look for them. 03/28/23 03:10 p.m. Resident #90 was observed lying in her bed and stated both ears hurt. It's not just my left ear, but the left ear is worse. Resident #90 said it has been going on for a while now and described feeling a pop then a clicking sound followed by a sharp pain sensation. She stated, have you ever been on an airplane when your ears feel like they're filling up, popping, and then followed by pain? Well, that's how it feels and am not on a airplane. Resident #90 went on to state I went to the audiologist appointment, he wouldn't even test me for the test. On 03/28/2023 at 3:20 p.m. a second interview was conducted with the SWA who stated, the audiologist would not take her insurance. She said she would be call the audiologist office for a report. On 03/29/2023 at 9:17 a.m. an interview was conducted with the Director of Nursing (DON). She stated Resident #90 has an audiology appointment for April 25. She said that the facility had been in the process of trying to get a brand-new audiologist to come to the facility. The DON said we have a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105733 If continuation sheet Page 9 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/30/2023 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 0685 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few new audiologist that is coming in on Friday, but was unaware if the new Audiologist would see the resident at that time. She spoke about the process of the resident needing to sign up for the service. The DON stated as of now we are keeping the appointment that is scheduled for April 25 just in case. She went on to say we have since received new orders for debrox drops for Resident #90 ears. On 03/29/2023 at 9:23 a.m. an interview was conducted Staff Member B, Certified Clinical Specialist who confirmed she had set up the appointment for Resident #90 audiologist appointment on 02/21/2023. She said the audiologist had seen her but could not recall what the resident had told her after she returned. She said had called the audiologist office and informed them it was for cleaning out her ears, and possible hearing aids, saying I then provided them with her insurance number. Staff B went on to say she could not remember if her insurance had changed from the time the appointment was made to the actual appointment date (a four-day period). She said she would look into if a change of pay had occurred. The facility did not have a policy or procedure in place for a hearing services. Prior to exiting the facility on 03/30/2023 at 4:50 p.m. no information was provided from the facility for Resident #90 audiologist appointment on 02/21/2023 and no information was provided related to a payer change. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105733 If continuation sheet Page 10 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/30/2023 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 review, and interviews, the facility failed to ensure the Consulting Pharmacist recommendations were addressed in a timely manner for one (#4) out of five residents sampled for the task of unnecessary medications. Findings included: Resident #4 was observed, on 3/27/23 at 7:34 a.m., sitting in a wheelchair between the two beds in the room. On 3/28/23 at 9:10 a.m., the resident was observed sitting in a wheelchair in between the two beds of the room. The resident was observed on 3/29/23 at 8:55 a.m., sitting in wheelchair at the units nursing station and was able to propel self. A review of the admission Record identified that Resident #4 was originally admitted on [DATE] and recently readmitted on [DATE]. The record included diagnoses not limited to Type 2 Diabetes Mellitus and moderate protein-calorie malnutrition. The review of Resident #4's active physician orders indicated the following orders: - Insulin Detemir solution 100 unit/milliliter (mL) - Inject 15 unit subcutaneously in the morning for Type 2 Diabetes Mellitus (T2DM), started on 3/16/23. - Insulin Detemir solution 100 unit/milliliter (mL) - Inject 10 unit subcutaneously in the evening for Type 2 Diabetes Mellitus (T2DM), started on 3/17/23. - Novolog FlexPen solution pen-injector 100 unit/mL (Insulin Aspart) - Inject as per sliding scale: if 151-200 = 2 units; 201-250 = 4 units; 251-300 = 6 units; 301-350 = 8 units; 351-400 = 10 units; 401-500 = 15 units administer and call physician (MD), subcutaneously before meals and at bedtime for Diabetes Mellitus, started on 7/28/22. The pharmacy's Consultation Report, dated 10/15/22, commented that Resident #4's dose of Levemir was recently changed on 7/23/22, but I am unable to locate a follow up lab assessment to evaluate the result of that change. The consultant's recommendation was Please consider monitoring a A1c on the next convenient lab day. This report was unsigned by the provider and did not include documentation that the facility had responded to the recommendation. The pharmacy consulting report, dated 11/11/22, did not identify no new irregularities. The pharmacy consulting report, dated 12/6/22, did not identify no new irregularities. The pharmacy's Consultation Report, dated 1/9/23, commented REPEATED RECOMMENDATION from 10/15/22: Please respond promptly to assure facility compliance with Federal regulations. The report that Resident #4's dose of Levemir had been changed on 7/23/22 and the consultant was unable to locate any follow up lab assessment. Recommendation: Please consider monitoring a A1c on the next convenient lab day. Handwritten in the corner of the report was 3/29/23 and initials. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105733 If continuation sheet Page 11 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/30/2023 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 A review of Resident #4's Hemoglobin A1c laboratory results identified that on 7/19/22 the residents result was 10.1, which was high as the reference range was 4.0-6.0. The Hemoglobin A1c results on 7/20/22 was 10.1 (high), the Hemoglobin A1c on 7/21/22 was 10.0 (high), and on 7/23/22 the Hemoglobin A1c that was collected at 6:00 a.m. was 9.6 (high). A physician order dated 3/22/23 indicated that Resident #4 was to have a Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), and a Hemoglobin A1c laboratory was to drawn every night shift every 3 month(s) starting on the 1st for 1 day(s) for routine labs. The Order Summary Report indicated that this order was to start on 4/1/23. An order, dated 3/28/23 at 10:06 p.m., identified that the resident was to have a Hemoglobin A1c (HGBA1C) drawn every night shift every 3 months starting on the 28th for 2 days related to Type 2 Diabetes Mellitus without complications. The order report identified that the HGBA1C was to be drawn on 3/28/23. The Hemoglobin A1c results, drawn on 3/29/23, indicated a level of 7.2 which continued to be high. On 3/29/23 at 1:17 p.m., the Director of Nursing (DON) stated that the Unit Manager's were putting the (pharmacy) recommendations in the physician books and the previous pharmacist had the wrong doctors name on them, the physicians were signing them but follow up was not being done. The DON reported being unable to locate the (physician) signed January recommendation and did not know if the physician had seen it (recommendation) or not. She identified that a performance improvement plan (PIP) was started in January. The DON stated that she had called last night (3/28/23) and informed staff that an A1c needed to be drawn and was awaiting the results. The Consultant Pharmacist stated, on 3/30/23 at 12:41 p.m., that the recommendations would ideally be addressed within 30 days, would expect them to be done by the next month. The consultant reported that a Hemoglobin A1c should be drawn every 6 months to a year and that a A1c was recommended in February. The facility policy - Medication Regimen Review, effective 12/1/07 revised on 11/28/16 and 3/3/20, identified that This Policy 9.1 sets forth procedures relating to the medication regimen review (MRR). The procedure indicated that: - 7. Facility should encourage Physician/Prescriber or other Responsible Parties receiving the MRR and the Director of Nursing to act upon the recommendations contained in the MRR. -- 7.1 For those issues that require Physician/Prescriber intervention, Facility should encourage Physician/Prescriber to either accept and act upon the recommendations contained within the MRR or reject all of some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected. -- 7.2 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. - 8. Facility should alert the Medical Director where MRR's are not addressed by the attending physician in a timely manner. - 11. The attending physician should address the consultant pharmacist's recommendation no later than their next scheduled visit to the facility to assess the resident, either 0 or 60 days per applicable regulation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105733 If continuation sheet Page 12 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/30/2023 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to follow infection prevention and control procedures related to antibiotic stewardship for two (#12 and #28) of three resident reviewed for prophylactic antibiotic use. Residents Affected - Few Findings include: 1. According to admission records, Resident #12 was a [AGE] year old female admitted on [DATE] from a local hospital after suffering an unwitnessed ground level fall. Her past medical history included atrial fibrillation with implanted cardiac pacemaker, type 2 diabetes mellitus, congestive heart failure, anxiety disorder, major depressive disorder, severe dementia, and urinary frequency. Review of Resident #12's medical record revealed an antibiotic order dated 6/4/22 for Hiprex Tablet (Methenamine Hippurate) 1 gram two times daily for chronic Urinary Tract Infection (UTI) prophylaxis. Further review of Resident #12's medical record failed to show consideration of the risks versus benefits supporting long term use of antibiotic mediation for UTI prophylaxis. 2. According to admission records, Resident #28 was a [AGE] year old female long term resident admitted on [DATE]. Her past medical history included right lower leg cellulitis, chronic kidney disease, anxiety disorder, type 2 diabetes mellitus, major depressive disorder, and anxiety disorder. On 03/27/23 at 07:44 AM Resident #28 was interviewed in her room and communicated she was on intravenous antibiotics for cellulitis of her right leg. Resident was observed with a Peripherally Inserted Central Catheter (PICC) in her left inner upper arm. Review of Resident #28's medical record revealed two active antibiotic orders; Vancomycin 1.7 grams intravenous daily for cellulitis, and Nitrofurantoin (Macrobid) macrocrystal capsule 100 milligrams by mouth daily for UTI prophylaxis dated 10/14/21. Further review of Resident #28's medical record failed to reveal consideration of the risks versus benefits supporting long term use of antibiotic mediation for UTI prophylaxis. A phone interview was conducted with the Consultant Pharmacist on 03/30/23 at 12:54 PM. During the interview he stated that he had mixed feelings on antibiotic prophylaxis for prevention of UTIs but current consensus is not to use antibiotics prophylactically. He said UTIs are difficult to prevent and sometimes families want antibiotics. The Consultant Pharmacist reviewed notes on Resident #28 and confirmed she had been on the Nitrofurantoin since 10/14/21 and recommendations to discontinue the medication were made on 2/4/21, 5/7/21 and 3/7/22 with no action was taken. The facility policy Infection Prevention and Control Manual Antibiotic Stewardship and MDROs dated December 2020 revealed: -Stewardship involves identifying the microbe responsible for disease, utilizing evidence based definitions when indicated; selecting the appropriate antibiotic along with documentation including rationale for use, appropriate dosing, route, and duration of antibiotic therapy; and ensure discontinuation of antibiotics when they are no longer needed. -Tracking and Reporting: Tracking and reporting of antibiotic use and outcomes will be completed in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105733 If continuation sheet Page 13 of 14 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105733 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/30/2023 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 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete the facility to identify adherence to facility policy and procedures, use and outcomes. Tracking will allow the facility to identify patterns, prevalence of antibiotic use as well as specific ordering data. Outcomes (i.e. adverse drug events, antibiotic resistance organisms, C difficile infections, etc.) will be tracked by the infection Preventionist and discussed with the Quality Assurance Committee for action planning. -Paragraph 6 under Procedure Prophylactic medication use in the facility will be limited based on practitioner documentation of rationale, risk, and benefits for use. Event ID: Facility ID: 105733 If continuation sheet Page 14 of 14