Inspection·April 16, 2021

DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 04/30/2021 CENTERS FOR MEDICARE & MEDICAID SERVICES FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING 01, 05 (X3) DATE SURVEY COMPLETED R 04/16/2021 NAME OF PROVIDER OR SUPPLIER 106063 B. WING STREET ADDRESS, CITY, STATE, ZIP CODE GLENRIDGE ON PALMER RANCH INC. 7333 SCOTLAND WAY SARASOTA, FL 34238 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION PREFIX TAG (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PREFIX TAG (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE (X5) DEFICIENCY) COMPLETION DATE [K 000] INITIAL COMMENTS [K 000] A follow-up by desk review was conducted on 4/16/21 for Glenridge on Palmer Ranch Inc., a skilled nursing facility in Sarasota, Florida. The follow-up was in response to the Fire and Life Safety recertification survey completed on 2/16/21. Glenridge on Palmer Ranch Inc. is in compliance with Code of Federal Regulations (CFR) 42, Section 483.90(a)(8)(b), Physical Environment Requirements for Long-Term Care Facilities and the National Fire Protection Association (NFPA) 101 (2012 edition) Life Safety Code. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Electronically Signed 04/23/2021 Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:N29522 Facility ID: 35960994 If continuation sheet Page 1 of 1 Agency for Health Care Administration PRINTED: 04/30/2021 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: 01, 05 B. WING ______ (X3) DATE SURVEY COMPLETED 35960994 R 04/16/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENRIDGE ON PALMER RANCH INC. 7333 SCOTLAND WAY SARASOTA, FL 34238 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X6) COMPLETE DATE (K 000) INITIAL COMMENTS (K 000) A follow-up by desk review was conducted on 4/16/21 for Glennridge on Palmer Ranch Inc., a skilled nursing facility in Sarasota, Florida. The follow-up was in response to the Fire & Life Safety relicensure survey completed on 2/16/21. All previously cited Fire & Life Safety deficiencies were corrected. AHCA Form 3020-0001 LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X8) DATE Electronically Signed 04/23/21 STATE FORM 6809 N29S22 If continuation sheet 1 of 1