Inspection·April 30, 2021

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of resident #27's medical record revealed she was admitted to the facility on [DATE]. Review of the diagnosis sheet revealed diagnoses to include seizures, abnormalities of gait, muscle weakness, and contracture of left hand. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Cognition/Brief Interview for Mental Status (BIMS) score 15 of 15, which indicated intact cognition. Activities of Daily Living - Total dependence for transfers (with two person assist), Extensive with one person for bed mobility, Total dependence with one person for dressing. On 4/29/21 at 8:30 a.m., during an interview with the Nursing Home Administrator (NHA) and the Director of Nurses (DON), they revealed that the observation of Staff D, who transferred the resident in a mechanical lift by herself was new and had not received the facility wide education regarding mechanical lifts that was done in February 2021. However, she was educated as of yesterday 4/28/21 and when the observation of the 4/27/21 transfer occurred. On 4/29/21, the Nursing Home Administrator provided the facility's Mechanical Lift policy and procedure with last revision date 1/2021, for review. The policy revealed: Purpose, 1. To lift and move a resident with limited mobility in a safe and secure way; 2. To reduce risk of injury to clinical staff. Under the procedure section of the policy, #8 revealed, per assessment required staff assistance is used. On 4/30/21 at 2:30 p.m., an interview with the Nursing Home Administrator and the Director of nursing revealed that the interpretation in this case per assessment required staff assistance is used, meant to have two person assist when utilizing the mechanical lift for resident #27. The Nursing Home Administrator said that when any resident required a two person assist with transfers, staff were to ensure there were two people in the room and assisting the resident with transfers, while utilizing the mechanical lift. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105736 If continuation sheet Page 2 of 7 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 105736 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Sun City 3850 Upper Creek Dr Sun City Center, FL 33573 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that one (Resident #80) of three sampled residents received treatment and care in accordance with professional standards of practice related to wound treatments. Residents Affected - Few Findings Included: Observation of lunch service on 4/27/21 at 12:15 p.m., revealed Resident #80 with a right elbow dressing dated 4/22/21. During an interview with the resident, she stated during care the CNA (Certified Nursing Assistant) pulled her up in bed and scraped her elbow. During an interview with Staff I, Licensed Practical Nurse (LPN) on 4/27/21 at 12:30 p.m., she confirmed the date of the dressing was 4/22/21 and confirmed she could not locate an order for the dressing or wound care. She confirmed that on 4/18/21, the resident received a skin tear while a CNA was pulling the resident up in bed by herself. She said a two person assist should be used when pulling a resident up in bed. Review of physician orders did not reflect wound care for the right elbow. Review of the Change in Condition Evaluation form dated 4/18/21 read as follows, Patient got [a] skin tear while CNA was pulling her up in bed by herself. Two persons should pull up in bed. Review of the care plan focus area included activities of daily living (ADL) self-care and/or mobility deficit. Interventions included mobility - limited to extensive assist times one and times two for pulling up in bed initiated and revised on 3/31/21. Review of the CNA [NAME] reflected bed mobility - limited to extensive assist times one and times two for pulling up in bed. Updated 4/29/21. During an interview with the DON on 04/29/21 4:25 p.m., she stated she did investigate and communicate with the nurse that documented the incident report. The DON confirmed that the resident should have had an order for a dressing change and wound care. Review of the facility policy without a date, titled, Wound Care Protocols revealed: 1. Notify physician, nurse practitioner, or physician assistant to report: location, size, and type of wound. Obtain definitive diagnosis for type of skin. 2. Obtain order for treatment including: dressing- obtain orders as needed. Review of facility policy titled, Charting and Documentation, effective date 10/2020, read as follows, 1. A complete account of the resident's care treatment, response to the care, signs, symptoms, etc. as well as the progress of the resident's care. 2. Guidance to the physician in prescribing appropriate medications and treatments. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105736 If continuation sheet Page 3 of 7 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 105736 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Sun City 3850 Upper Creek Dr Sun City Center, FL 33573 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to conduct a root cause analysis of falls to ensure appropriate and effective interventions were in place to prevent additional falls and injuries for one (Resident #29) of three sampled residents. Findings included: Review of the Incident log revealed Resident #29 sustained unwitnessed falls on 3/14/21, 3/23/21, 3/31/21, and 4/22/21. Review of Resident #29's admission Record revealed he was originally admitted to the facility on [DATE]. According to the admission Record, the resident's admitting diagnoses included unspecified dementia with behavioral disturbance, repeated falls, and adult failure to thrive. Review of the nursing progress notes dated 3/14/21 at 1:27 p.m. revealed the resident was found on the floor in another resident's room by staff. He was sitting on the floor next to his chair and the dresser. He was wearing non-skid socks. He had a small skin tear to mid-upper back. Resident was smiling saying he was trying to go to the bathroom. Cleansed skin tear to mid upper back with normal saline and applied band aid. No signs or symptoms of discomfort noted. A review of the SBAR (Situation, Background, Appearance, and Review) Communication Form dated 3/14/21 at 12:00 p.m. revealed the Situation being evaluated was a fall and this had occurred before. The form indicated that the physician was informed of the fall with recommendations to follow facility protocol and initiate neuro-checks. The form provided no additional details surrounding the 3/14/21 fall. A review of an Evaluation of Fall Risk form completed post fall on 3/14/21 at 12:00 p.m. revealed Resident #29 had 1 or 2 falls in the past month, had confusion/dementia, had Alzheimer's, used a wheelchair, had difficulties with transfers, had unsteady gait, and received antipsychotic medications. The resident's fall score was 9 indicating moderate risk. The evaluation noted that the resident was at risk for falls and had a goal to strive for falls and/or injuries to be minimized through management of risk factors while maintaining independence and quality of life. Interventions listed to help reach this goal included: encourage appropriate footwear, keep adaptive equipment within reach, observe for unsafe actions and intervene as needed, and observe for unsafe ambulation. A review of Resident #29's active care plan for a focus area of fall risk to include goal and intervention dates going back to 8/12/20 revealed one intervention was added following the 3/14/21 fall: Offer toileting upon rising, before, and after meals and at HS (hour of sleep/bedtime). Continued review of the care plan revealed a focus area initiated on 8/12/20 for incontinence of bladder related to history of incontinence and impaired cognitive status. This incontinence care plan included the same intervention to toilet the resident upon waking, before and after meals, and at HS. This care plan intervention had been initiated on 8/12/20. An interview was conducted with the Nursing Home Administrator (NHA) on 4/29/21 at 4:30 p.m., he stated he was the Risk Manager, but the previous Director of Clinical Services would investigate the incidents and they would discuss the events every morning. The NHA confirmed he was unable to find (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105736 If continuation sheet Page 4 of 7 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 105736 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Sun City 3850 Upper Creek Dr Sun City Center, FL 33573 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the fall investigation for 3/14/21, but could bring in someone that remembered the events. The NHA stated he could get some of the information about the falls from the computer but did not have the fall packet which included the witness statements and events surrounding the fall. On 4/30/21 at 9:41 a.m., an interview was conducted with the Nursing Home Administrator (NHA) and Staff F, Licensed Practical Nurse (LPN) Care Plan Specialist. Staff F was unable to provide the investigation, fall packet, witness statements, or root cause analysis related to the fall on 3/14/21. Continued review of the clinical record revealed a nursing progress note dated 3/23/21 at 9:00 a.m. The note documented that during nurse to nurse report shift change, Certified Nursing Assistant (CNA) reported finding resident on floor next to his bed. Sitting with his hands on his knees. He was bleeding form a skin tear to the palm of his right hand and skin tear between his 3rd and 4th fingers. Also had a small tear to the tip of the 1st finger and right forearm with bruising to hand and fingers. Resident was asleep in bed before the fall. He said he did not know what happened. Resident transferred back to bed. A review of the SBAR Communication form associated with the 3/23/21 fall revealed the physician was notified on 3/23/21 at 7:50 a.m. and interventions were listed as dress skin tears with gauze. A review of an Evaluation of Fall Risk form completed post fall on 3/23/21 at 12:00 p.m. revealed Resident #29 had 1 or 2 falls in the past month, had confusion/dementia, was incontinent of bowel and bladder, used a wheelchair, had difficulties with transfers, had unsteady gait, and received laxatives. The resident's fall score was 15 indicating high risk. The evaluation contained the same goal and interventions noted on the 3/14/21 fall evaluation. A review of Resident #29's active care plan for a focus area of fall risk to include goal and intervention dates going back to 8/12/20 revealed no evidence that additional interventions were added following the 3/23/21 fall. On 4/30/2021 at 9:41 a.m., an interview was conducted with the Nursing Home Administrator (NHA) and Staff F, LPN Care Plan Specialist. Staff F was unable to provide the investigation, fall packet, witness statements, or root cause analysis related to the fall on 3/23/21. Continued review of the clinical record revealed a nursing progress note dated 3/31/21 at 4:21 a.m. The note documented that staff heard stumbling noise, went to investigate, observed resident sitting on the floor beside his bed. Assessed resident and noted skin tear to right forearm. Area cleansed with normal saline and dry dressing applied. Resident assisted to wheelchair. Initiated neuro checks and notified physician and family. A review of the SBAR Communication form associated with the 3/31/21 fall revealed the physician was notified on 3/31/21 at 4:00 a.m. and no new orders or interventions were received at that time outside of neuro checks. A review of an Evaluation of Fall Risk form completed post fall on 3/31/21 at 3:00 a.m. revealed Resident #29 had 1 or 2 falls in the past month, had confusion/dementia, was incontinent of bowel and bladder, used a wheelchair, and had unsteady gait. The resident's fall score was 12 indicating high risk. The evaluation contained the same goal and interventions noted on the 3/14/21 fall evaluation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105736 If continuation sheet Page 5 of 7 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 105736 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Sun City 3850 Upper Creek Dr Sun City Center, FL 33573 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Continued review of the progress notes revealed a 3/31/21 nursing note at 4:44 p.m. noting the resident was alert, status post fall, increased confusion, needed greater assistance with activities of daily living (ADLs), and had pain to right hip when right leg was moved. Medical Doctor (MD) in the building examined patient and ordered him to the emergency room (ER). Tylenol given for pain, family notified, 911 contacted, and called in report to ER nurse. Emergency Medical Service (EMS) arrived and took resident to the ER via stretcher. The next nursing note dated 3/31/21 at 11:39 p.m. revealed the facility nurse called the hospital and was informed that Resident #29 was admitted for acute kidney failure. On 4/8/21 at 12:23 p.m., a MD note revealed This is a readmission H&P [History and Physical]. The resident fell while getting out of bed at the facility and complained of right hip pain so sent to the ER (on 3/31/21). Found to have a fracture of right superior and inferior rami and admitted for management. He then developed some respiratory issues due to acute exacerbation of COPD. Chest x-ray indicated a mass in right lung and a CT chest was indicative of a scar vs mass of right upper lobe with severe emphysema. A review of Resident #29's active care plan for a focus area of fall risk to include goal and intervention dates going back to 8/12/20 revealed one intervention was added following the fall on 3/31/21 which resulted in hospitalization and a diagnosis of positive superior and inferior right pubic rami fractures. The new intervention initiated on 4/8/21 was bolsters to side of mattress. On 4/30/21 at 9:41 a.m., an interview was conducted with the Nursing Home Administrator (NHA) and Staff F, LPN Care Plan Specialist. Staff F read the incident report from the computer and said the resident was found on the floor next to his bed on 3/31/21 at 3:00 a.m. The resident stated he was looking for the stairs. Interventions included bolsters to the air mattress. Later in the day the resident reported left hip pain. No injuries were found at the time of the fall. The physician gave orders to send to the hospital for evaluation and the progress notes revealed the resident was admitted for acute kidney failure. Staff F said when they received the admitting information it revealed a positive pelvic fracture. Staff F stated, Therapy picked up the resident and they added bolsters on the air mattress when he returned. The Interdisciplinary Team (IDT) reviewed the care plan and interventions and determined the care plan was being followed and effective at the time of the fall. Staff F was unable to provide the investigation, fall packet, witness statements, or root cause analysis related to the fall on 3/31/21. Continued review of the clinical record revealed a nursing progress note dated 4/22/21 at 5:33 a.m. The note documented the resident was observed on the floor in his room lying on his right side. Patient assessed and was able to move all extremities without pain. Resident transferred to wheelchair by two staff. Toileted, given food and drink. Physician and family aware. A review of the SBAR Communication form associated with the 4/22/21 fall revealed the physician was notified on 4/22/21 at 4:44 a.m. and interventions were listed as none. A review of an Evaluation of Fall Risk form completed post fall on 4/22/21 at 4:00 a.m. revealed Resident #29 had 1 or 2 falls in the past month, had confusion/dementia, had Alzheimer's, was incontinent of bowel and bladder, used a wheelchair, had unsteady gait, had a safety device ordered and received cardiac, antipsychotic, and anti-anxiety medications. The resident's fall score was 16 indicating high risk. The evaluation contained the same goal and interventions noted on the 3/14/21 fall evaluation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105736 If continuation sheet Page 6 of 7 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 105736 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Sun City 3850 Upper Creek Dr Sun City Center, FL 33573 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 0689 Level of Harm - Minimal harm or potential for actual harm A review of Resident #29's active care plan for a focus area of fall risk to include goal and intervention dates going back to 8/12/20 revealed the bolsters to the side of the mattress were canceled on 4/22/21 and a scoop mattress with floor mats next to the bed was initiated. Additionally, on 4/29/21, one week after the most recent fall, an intervention of PALM (preventing accidental level change mishaps) program was initiated. Residents Affected - Few On 4/30/21 at 9:41 a.m., an interview was conducted with the Nursing Home Administrator (NHA) and Staff F, LPN Care Plan Specialist. Staff F was unable to provide the investigation, fall packet, witness statements, or root cause analysis related to the fall on 4/22/21. On 4/30/21 at 11:15 a.m., Staff H, LPN stated the resident had falls that surrounded his confusion and transferring himself. Staff H stated the resident was no longer a fall risk as he had rapidly declined and been placed on hospice for co-morbidities. Staff H stated when a resident fell the process was to fill out a fall packet that included the CNA filling out a witness statement. Staff H stated, The nurse documents on the incident report in the computer and the documents related to the fall go to the Risk manager box or it's given to the supervisor. Staff H provided the surveyor with a fall packet. Review of the documents revealed a Falls Checklist that noted: The two most important issues related to falls are: 1. Root case analysis to determine what caused/contributed to the fall. 2. Putting an immediate intervention in place to prevent subsequent fall/injury. During an interview with Staff G, LPN/Unit Manager on 4/30/21 at 11:25 a.m., she confirmed that the nurses start the fall packet from the incident binder and incident form in the computer. The CNA was given their portion to fill out. Staff G stated, If it's at night, the packet goes in the front of the incident binder. The nurse is responsible for completing the incident report in the computer and fall packet then either giving it to me or they can place it in the front of the incident binder. Every morning the incident binder is checked and discussed in the morning meeting. The packet then goes to the Risk Manager after it's completed. Review of the facility policy for Falls, revised in November 2018, one page revealed: To identify and address risk factors associated with resident falls to decrease the likelihood of falls. 1. After a resident has fallen a comprehensive risk evaluation will be completed by the interdisciplinary team to include as appropriate. 2. The evaluation may include but will not be limited to the following: cause of fall or contributing risk factors if known, review of medications to include pharmacy intermediate medication regimen review, review of any assistive or safety devices currently in use, therapy screen, recommendations of the team to address fall risk factors. 3. Review and revise care plan with new interventions. Review of the facility policy for Incidents-Risk Management effective date 11/30/17, one page, revealed: The IDT team reviews incidents using risk management module and proceeds with additional investigation as needed. Interventions implemented as appropriate to maintain resident/guest safety. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105736 If continuation sheet Page 7 of 7