Inspection·August 25, 2022

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicated there was no Personal Effect Inventory Form for Resident #250. The electronic record did not include a Personal Effect Inventory Form. Staff H, RN stated, on 8/23/22 at 3:50 p.m., the facility (staff) were to do a resident's inventory sheet at admission and then put it into the medical record folder for it to be uploaded. The staff member reported residents are allowed to have personal items on the COVID-19 Unit and she had called Social Services yesterday after the resident had reported not having personal items. A review of the July 2022 and August 2022 Grievance/Complaint Logs did not indicate a grievance was filed by the resident or on behalf of the resident in regard to the missing personal items. On 8/23/22 at 3:57 p.m., Staff I, Social Services (SS) stated she did not know about Resident #250's missing items and would never tell anyone that they couldn't have personal items on the COVID unit. She reviewed the uploaded documents in the resident's electronic record and indicated the resident did not have an inventory sheet. Staff I identified the personal inventory sheets are to be uploaded into the electronic record. Staff I asked the Environmental Services Director (ED) if he was aware of the resident's missing personal items and replied that he would have to check. During the task of Medication Administration, on 8/23/22 at 4:19 p.m., Resident #250 was observed sitting on the side of the bed wearing a blue hospital gown. On 8/23/22 at 4:43 p.m., the ED identified he had located three items belonging to the resident. The ED and Staff I, SS stated, on 8/23/22 at 5:07 p.m., the facility had located one more pair of the resident's pants and the clothing was not labeled with the resident's name. Staff I indicated a grievance for the missing clothing was filed on behalf of the resident. Staff I stated, at 5:20 p.m. on 8/23/22, she had asked the Nursing Home Administrator regarding the procedure for personal effects and he informed her that staff are to encourage family members and residents to complete a Personal effect form. The grievance filed on behalf of Resident #250 identified the resident had reported missing items and the incident occurred on 8/12/22 when the guest moved to the COVID unit. The facility's Grievance policy and procedure, effective March 2015 and revised January 2018 and July 2021, identified the Policy as: The center recognizes the resident/legal representative/family has the right to voice grievances and recommendations for changes through an orderly and timely process free from discrimination and/or reprisal. They have a right to expect the center will make prompt efforts to resolve grievances and, upon request, have the right to obtain written decision regarding the grievance. The procedure portion of the policy identified the following: - A concern is defined as any formal expression of interest regarding the well-being of a resident. - Formal concerns may be registered by telephone, mail, office, visit, or direct outreach to team members and must be indicated as a formal concern. - The Grievance Official center will oversee the grievance process, receiving and tracking grievances through their conclusions through investigating, document and follow up on all formal concerns and grievances registered by any resident/legal representative/family/concerned party. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105736 If continuation sheet Page 2 of 9 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 08/25/2022 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 0585 - The resident/legal representative/family/concerned party can expect that the center will review any grievance within 3-5 business days of receipt/notification of the concern. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105736 If continuation sheet Page 3 of 9 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 08/25/2022 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. 2. An observation was made of a kitchenette area in the corner of the 300-hall dining room. A surgical mask lay on the floor next to the freezer and inside the refrigerator was a fast food brown paper bag which did not identify when it was brought into the facility or a resident's name, another fast food white paper bag was observed undated and not labeled with a resident name, a white plastic bag from a commercial store and an opened individual-sized container of vanilla pudding with a spoonful missing from it. The observation of the kitchenette ice dispenser indicated wet-looking calcium buildup around the dispenser and the drainage grate. On 8/22/22 at 7:01 a.m., Staff H, Registered Nurse (RN) identified the kitchenette area on the 300-hall was used. An interview was conducted at 7:33 a.m. on 8/22/22, with Staff H and Staff J, Certified Nursing Assistant (CNA). Staff H stated the kitchenette's refrigerator was for residents. Staff J observed the refrigerator immediately following the interview. The white plastic bag had been removed and the Staff J, CNA confirmed both the brown and white fast-food bags were not labeled with a resident name or dated, and the vanilla pudding was opened, had been eaten, and should not be in the refrigerator. She removed the pudding cup and threw it away. Staff J stated when food was brought into the facility she puts the name of the resident on it, the date, and the resident's room number. On 8/22/22 at 8:50 a.m. the unlabeled, undated fast food bags continued to be observed in the refrigerator. The ice dispenser continued to have calcium buildup inside and out. (Photographic Evidence Obtained) On 8/24/22 at 11:15 a.m. an observation was conducted with the NHA, the CDM, and another surveyor. The cool temperature dishwasher was started and the temperature gauge indicated a temperature of 96 degrees Fahrenheit, which was confirmed by the NHA. The dishwasher was tested two more times with approximately one minute in between tests and the temperature rose to 100 degrees Fahrenheit. The NHA informed the CDM to use paper products for the next meal service. The CDM stated the temperature for the dishwasher was to be taken prior to washing dishes. An observation of the dishwashing machine temperature log, hanging at the entrance to the dishwashing room indicated temperatures were not taken on 8/23/22 for the evening meal or on 8/24/22 for the morning meal. The CDM identified both the night before dinner dishes and that day's breakfast dishes had been washed. Based on observation, interview and policy review, the facility failed to maintain clean and sanitary equipment in the kitchen area related to the dish machine, ice machines, convection ovens, walls and floors, and failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety related to labeling and dating of food, recording temperatures for refrigeration and for the dish machine and failed to utilize sanitizing buckets in the kitchen for three days (8/22/22, 8/23/22 and 8/24/22) of a four day survey. Findings included: On 08/22/2022 at 7:02 a.m., the initial tour was partially conducted with Staff E, Dietary Aide. An observation of the walk-in cooler revealed no thermometer found inside the cooler. Also observed were food items were not labeled or dated to include: 1/2 bag of open shredded cheddar cheese, opened bag of bologna 1/4 bag full of shredded cabbage, open jar of grape jelly, 1/2 opened bag containing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105736 If continuation sheet Page 4 of 9 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 08/25/2022 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 6 slices of pre-cooked French toast, 1-half used gallon of coleslaw dressing, 2 open bags of whipped topping, 1 gallon jug of pickles approximately half full, 1/2 jug of mayonnaise, 1/2 full bucket of hard boiled eggs, ¾ of a gallon container of Italian dressing. The floor had dirt-build up and some unknown dried brown liquids. (Photographic Evidence Obtained) An observation of the walk-in freezer showed evidence of melted ice cream that spilled and was frozen to the floor. Multiple items to include ice cream cups, frozen non-dairy dessert cups were found scattered on the freezer floor. The floor was observed dirty with buildup of dirt and debris, and unknown frozen food items and a frozen water bottle alongside of the metal shelf. (Photographic Evidence Obtained) Additional observations during the tour revealed no sanitizing buckets being used. Three red buckets with cloths inside were observed on the bottom shelves of three individual worktables and had no sanitizing solution in them. The filters over the stove and ovens were observed covered in grease. Two of two convection ovens had burnt-on food inside, on the bottom of the ovens. The glass doors of the convection ovens were covered with food splatter and grease. (Photographic Evidence Obtained) An additional observation revealed dirt, crumbs, straws, a sleeve of white plastic lids, plastic cups, several clear plastic lids, diet sugar packs, creamers, and pre-portioned 4 ounce juice cups found on the floor behind the juice dispensing system. (Photographic Evidence Obtained) The kitchen floor was observed to be dirty and sticky throughout during the tour. There were missing tiles along the floor and wall in the dish-room. The wall board underneath the dish-machine was falling off the wall and covered in dirt and dried on food splatter. The floor in the corner under the dish-machine had an extensive amount of dirt and build up. The wall underneath the opening for clearing dishes in the dish-room was splattered with dried food. The ice machine had red stains on the white plastic that sits above the ice. (Photographic Evidence Obtained) During the tour at 7:52 a.m. on 8/22/22, the Certified Dietary Manager (CDM) arrived and a request was made for the past three months of completed cleaning schedules. He stated he would look for them and submit copies. On 8/22/22 at 2:15 p.m. a second request was made to the CDM for the completed cleaning schedules. On 8/23/22 at 7:36 a.m. an interview with the Nursing Home Administrator (NHA) was conducted and a third request was made for copies of the past three months of cleaning schedules, along with a request for the facility's policy and procedure for labeling and dating of food. On 8/23/22 at 11:00 a.m. the NHA stated the CDM did not have any of the previous cleaning schedules completed or available for review. A review of the Dish Machine Log for August 2022 revealed no recorded temperatures for the Supper shift the day prior (8/23/22) and the Breakfast shift for 8/24/22. On 8/24/22 at 11:00 a.m. a second tour of the kitchen with the CDM was conducted. The issues observed on the initial tour were observed not to be corrected and were as follows: 1. The walk-in cooler still had no thermometer. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105736 If continuation sheet Page 5 of 9 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 08/25/2022 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 0812 2. The food items still did not have labels and or dates. Level of Harm - Minimal harm or potential for actual harm 3. The cooler floor was not cleaned. Residents Affected - Some 4. The walk-in freezer still had melted ice cream that spilled and was frozen to the floor. 5. Ice cream cups, frozen non-dairy dessert cups were still observed on the floor. 6. The floor was still dirty with buildup of dirt and debris. 7. Observed the unknown frozen food items and a frozen water bottle still alongside of the metal shelf. 8. No sanitizing buckets in use. 9. Ovens were still dirty with burnt on food and grease build up. 10. The dirt, crumbs, and straws along with a sleeve of white plastic lids, plastic cups, several clear plastic lids, diet sugar packs, creamers, and pre-portion juice cups were found still on the floor behind the juice dispensing system. 11. Observed the missing tiles in the dish-room. The wall board underneath the dish-machine was not fixed, 12. The floor in the corner under the dish-machine still had an extensive amount of dirt and not cleaned. 13. The wall underneath the opening for clearing dishes in the dish-room was still stained and dirty. Immediately following the walk-through, an interview was conducted with the CDM. He stated he tried to get the issues corrected but was short staffed and was not able to. The facility did not provide a copy of the policy and procedure for labeling and dating of food by the completion of the survey. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105736 If continuation sheet Page 6 of 9 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 08/25/2022 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to implement an effective infection control program related to transmission-based precautions by not ensuring five staff members (L, H, A, C, D) adhered to the appropriate use of Personal Protective Equipment (PPE) for four residents (#31, #249, #148 and #76) with the potential to affect a census of 113 residents. Residents Affected - Some Findings included: 1. An observation of medication administration was conducted, on 8/23/22 at 4:44 p.m., with Staff L, Licensed Practical Nurse (LPN), for Resident #31. The nurse entered the resident's room, administered one oral medication then administered eye drops into bilateral eyes while standing over the resident who was lying in bed. After leaving the resident's room, the staff member utilized hand sanitizer. The area outside of Resident #31's room did not include any Personal Protective Equipment (PPE) and the room's door was not posted with any signs indicating if precautions should be observed prior to entering the resident's room. (Photographic Evidence Obtained) The review of the August 2022 physician orders and Treatment Administration Record (TAR) on 8/24/22 at 10:04 a.m. identified an order, dated 8/23/22 at 12:28 p.m., for Stool for C.diff (Clostridioides difficile)- one time only for diagnostic for 1 day. An interview was conducted on 8/24/22 at 10:10 a.m. with Staff K, Registered Nurse (RN). She confirmed Resident #31 was being investigated for C.diff and no stool had been obtained. The staff member reported residents being investigated for C.diff should be in isolation and stated, She isn't? I forgot to write the order. I'll write it now. Staff M, LPN stated on 8/24/22 at 12:45 p.m. that Resident #31 was moved to a private room due to being under investigation for C.diff. An observation of the area outside of Resident #31's current room identified visitors should utilize Contact precautions (use of gloves and gown) when entering the room. During an interview on 8/25/22 at 12:00 p.m. the Infection Preventionist (IP) reported in order to determine if isolation was needed, the facility checks lab results and checks to see the type of bacteria or C.diff. The IP stated soap and water should be used for a C.diff infection and Contact/Enteric precautions are needed for C.diff, which included gloves and a gown to be worn in the room. 2. Staff H, Registered Nurse (RN) reported on 8/22/22 at 7:13 a.m. there was only one resident (#249) in room [number] posted with a Droplet precaution sign. Staff H stated the resident was on Droplet precautions due to not being vaccinated (for COVID-19). An observation was conducted, on 8/22/22 at 8:56 a.m. of Staff H in the process of dispensing medication outside of Resident #249's room. The room was posted with a Droplet precautions sign on the door and with a drawer caddy on the floor outside of the room. The Droplet precautions sign indicated a person entering the room must wear gloves, a face mask, eye protection and a gown if splash is anticipated or aerosol generating procedure being performed. Staff H was observed entering Resident #249's room without donning a gown or gloves. Staff H was overheard encouraging the resident to take the medication. Staff H returned to the medication cart and stated she was supposed to wear a gown and gloves while in the resident's room and said, I forgot. No one is perfect. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105736 If continuation sheet Page 7 of 9 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 08/25/2022 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of the facility policy titled, Transmission Based Precautions, with an effective date of September 2019 and a revised date of December 2020, revealed the following: Transmission based precautions are used when route of transmission is not completely interrupted using standard precautions alone and the pathogen may have multiple routes of transmission. Transmission based precautions are divided into; Contact precautions, Droplet precautions, and Airborne precautions. Precautions in place when symptomatic infections are not deemed colonized by the resident Physician or Center Infection Preventionist. The policy indicated Contact precautions required PPE of gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident environment and to use when microorganisms are spread with direct or indirect contact with the resident or the resident's environment. Droplet precautions require PPE and a mask upon entry into the resident room when risk of exposure is present and to use when transmission of pathogens through close respiratory or mucous membrane contact with respiratory secretions are anticipated. Suspicion of communicable disease will have transmission-based precautions placed while awaiting lab test results. Residents will remain on appropriate precautions until the attending physician or Infection Preventionist recommends them discontinued. 3. Observations during the initial tour of the facility on 8/22/22 at 7:05 a.m. revealed a Contact precaution sign and a PPE kit hanging on Resident #148's door. Closer observation of the sign by the room door revealed this resident was housed in the window bed of the room. Continued observation at this time revealed Staff A, Certified Nursing Assistant (CNA) had walked in and out of Resident #148's room three times. Staff A, CNA was observed to be wearing a N95 mask. Continued observation at this time revealed at no time was Staff A observed to don any other PPE when entering the room. An interview on 8/22/22 at 7:10 a.m. with Staff B, LPN revealed Resident #148 was on Contact precautions due to Methicillin Resistant Staphylococcus Aureus (MRSA). She reported staff are to don PPE prior to entering the room and should definitely have on PPE when providing care to the resident. An interview on 8/22/22 at 7:15 a.m. with Staff A, CNA revealed she thought the resident in the door bed was on isolation. She reported that she should put on all PPE prior to entering the room, but I was just rushing because the resident had a bowel movement and was playing in the feces and it's all over the place. 4. Observations on 8/22/22 at 9:15 a.m. revealed Resident #76's room had a Droplet precaution sign as well as a PPE kit hanging on Resident #76's door. Continued observations at this time revealed Staff C, CNA went into Resident #76's room and retrieved the morning meal tray. Staff C, CNA was not observed to don any PPE prior to entering the room or while in the room. An interview with Staff C, CNA at this time revealed Resident #76 was on Droplet precautions and that she just ran into the resident's room quickly to get the meal tray. She reported that she knows she should have put on her PPE. While interviewing Staff C, CNA on 8/22/22 at 9:19 a.m. outside of Resident #76's room Staff D, LPN was observed in the room in and out of the resident drawers, organizing the drawers. Staff D, LPN was not wearing any type of PPE other than an N95 mask. An interview with Staff D, LPN at this time revealed she did have a gown on but took it off in the bathroom. When the observation of her was shared she reported, Oh yeah, that's right, after I took off the PPE I saw linens on top of dresser. She confirmed the resident is on isolation and she should have had on her PPE before entering the room. A continued review of the facility policy titled, Transmission Based Precautions, with an effective date of September 2019 and a revised date of December 2020, revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105736 If continuation sheet Page 8 of 9 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 08/25/2022 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 0880 Level of Harm - Minimal harm or potential for actual harm 1. Contact precautions: wear PPE (personal protective equipment) gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident environment. b. Apply when excessive blood, wound drainage, bodily fluids or fecal incontinence are present and there is risk of transmission. Residents Affected - Some 2. Droplet precaution: wear PPE and don a mask upon entering into the resident room when risk of exposure is present. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105736 If continuation sheet Page 9 of 9