Inspection·July 18, 2022

K 291 SS=D | NFPA 101 Emergency Lighting | K 291 | | 8/20/22 Emergency Lighting Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9. 18.2.9.1, 19.2.9.1. This Statute or Rule is not met as evidenced by: Based on facility tour and interview with the Maintenance Director, the facility failed to install battery back-up emergency lighting as required by NFPA 110. Battery back-up emergency lighting is required to insure the safety of building occupants in the event of power failure. Findings included: On 7/18/22 1:50 PM, while touring the facility with the Maintenance Director, it was observed in the enclosed generator room, a battery back-up emergency light was not provided. The Maintenance Director was unaware that one had Specific Corrective Action: No residents were adversely affected. However, corrective action was taken specific to the deficiency. On July 22, 2022 Sunshine Electrical installed the 1.5-hour duration battery back-up emergency light fixture in the emergency generator enclosure (Attachment A). The emergency light was tested on August 8, 2022 for 1.5-hour duration with no issues(Attachment B). Method to Assess Other Residents: No residents were adversely affected by AHCA Form 3020-0001 LABORATORY DIRECTOR OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Electronically Signed 08/11/22 STATE FORM 6809 OBZF21 If continuation sheet 1 of 9 PRINTED: 09/08/2022 FORM APPROVED Agency for Health Care Administration STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 35960994 (X2) MULTIPLE CONSTRUCTION A. BUILDING: 05 - MAIN LIC B. WING __ (X3) DATE SURVEY COMPLETED 07/18/2022 NAME OF PROVIDER OR SUPPLIER GLENRIDGE ON PALMER RANCH INC. STREET ADDRESS, CITY, STATE, ZIP CODE 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 291 Continued From page 1 not been installed. Concurrent with the observation and at the exit conference the Maintenance Director and Administrator acknowledged the findings. Per NFPA 101 (2018 edition) 9.1.3.1 and NFPA 110 (2016 Edition) 7.3.1 Class III K 291 this deficiency. Systems Review: A work order was issued to check and test all enclosures(including emergency generator enclosure) requiring 7.9, 18.2.9.1, & 19.2.9.1. All were tested on August 8, 2022 and passed (Attachment B). Quality Assurance: All enclosures requiring battery back-up emergency lighting will be checked and tested as required. Any identified issues will be reported to the Maintenance Director and a work order completed for repair. Maintenance Director will report all issues to the Administrator who will report to the Quality Assurance Committee as part of the Life Safety report.

K 324 NFPA 101 Cooking Facilities SS=D Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. K 324 8/20/22 AHCA Form 3020-0001 STATE FORM notes OBZF21 if continuation sheet, 2 of 9 Agency for Health Care Administration PRINTED: 09/06/2022 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 35960994 (X2) MULTIPLE CONSTRUCTION A. BUILDING: 05 - MAIN LIC B. WING __ (X3) DATE SURVEY COMPLETED 07/18/2022 NAME OF PROVIDER OR SUPPLIER GLENRIDGE ON PALMER RANCH INC. STREET ADDRESS, CITY, STATE, ZIP CODE 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 324 Continued From page 2

K 324 Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2 This Statute or Rule is not met as evidenced by: Based on record review and staff interview, the facility failed to maintain the commercial cooking hood in accordance with National Fire Protection Association (NFPA) 96. This in the event of a cooking fire could affect all the occupants of the smoke compartment. The findings included: On 7/18/22 between 9:00 a.m. and 12:30 p.m., during record review, a current commercial cooking hood semi-annual inspection could not be produced. The last inspection documented was 3/23/21. Concurrent with the observation and at the exit conference, the Maintenance Director and Administrator acknowledged the findings. Per NFPA 101 (2018 Edition) 19.3.2.5, 9.2.3 and NFPA 96 (2017 Edition) 11.2.1 Class III Specific Corrective Action: No residents were adversely affected. However, corrective action was taken specific to the deficiency. Documentation of the previous two semi-annual hood inspections (since the 3/23/2021 inspection noted in the statement of deficiencies), September 22, 2021 (Attachment C) and March 10, 2022 (Attachment D) is attached. Method to Assess Other Residents: No residents were adversely affected by this deficiency. Systems Review: Cooking hood inspection remains on a semi-annual inspection schedule. Next inspection is scheduled for September 6, 2022. Documentation of inspections will be forwarded to the Administrator and maintained by the Life Safety Director and will be readily available for review. Quality Assurance: Administrator will conduct regular audits of documentation related to the semi-annual hood inspections to ensure compliance and the documents are readily available for review. Audit results will be reported in the Quality Assurance meeting as part of the Life Safety report. AHCA Form 3020-0001 STATE FORM OBZF21 if continuation sheet, 3 of 9 PRINTED: 09/08/2022 FORM APPROVED Agency for Health Care Administration STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 35960994 (X2) MULTIPLE CONSTRUCTION A. BUILDING: 05 - MAIN LIC B. WING __ (X3) DATE SURVEY COMPLETED 07/18/2022 NAME OF PROVIDER OR SUPPLIER GLENRIDGE ON PALMER RANCH INC. STREET ADDRESS, CITY, STATE, ZIP CODE 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 353 SS=F

K 353 8/20/22 NFPA 101 Sprinkler System - Maintenance and Testing Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked b) Who provided system test c) Water system supply source Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Statute or Rule is not met as evidenced by: Based on record review and staff interview, the facility failed to maintain the automatic fire sprinkler system (AFSS) in accordance with NFPA 101. This in the event of fire this could reduce the reliability of the system and jeopardize the safety of the occupants in the facility. The findings included: On 7/18/22 between 9:00 a.m. and 12:30 p.m., during record review of the sprinkler inspection records, it was revealed that the facility failed to provide a 5-year hydrostatic test on the FDC as well as the 5-year internal inspection of the backflow system to verify that all components are unobstructed and operate correctly, move freely Specific Corrective Action: No residents were adversely affected. However, corrective action was taken specific to the deficiency. A copy of the 5-year hydrostatic test on the FDC, completed on August 12, 2021, was obtained (Attachment E), the 5-year internal inspection of the backflow system was completed on August 10, 2022 (Attachments F-1 & F-2). Method to Assess Other Residents: No residents were adversely affected by this deficiency. Systems Review: AHCA Form 3020-0001 STATE FORM notes OBZF21 If continuation sheet, 4 of 9 Agency for Health Care Administration PRINTED: 09/08/2022 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 35960994 (X2) MULTIPLE CONSTRUCTION A. BUILDING: 05 - MAIN LIC B. WING __ (X3) DATE SURVEY COMPLETED 07/18/2022 NAME OF PROVIDER OR SUPPLIER GLENRIDGE ON PALMER RANCH INC. STREET ADDRESS, CITY, STATE, ZIP CODE 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 353 Continued From page 4 and are in good working condition. Concurrent with the observation and at the exit conference, the Plant Operations Director and Administrator acknowledged the findings. per NFPA 101 (2018 Edition) 9.11.1, 9.11.3.2 per NFPA 25 (2017 Edition) 13.7.1.3, 13.8.5 Class III K 353 The 5-year hydrostatic test on the FDC and the 5-year internal inspection of the backflow system remain on a regular schedule. Next inspection of the FDC is due in 2026 and the next inspection of the backflow system is due in 2027. Quality Assurance: Documentation of both inspections will be maintained by the Life Safety Director and a copy forwarded to the Administrator and will be readily available for review. Administrator and Life Safety Director will monitor inspection schedule to ensure compliance and any issues will be reported to the Quality Assurance Committee as part of the Life Safety Report.

K 741 NFPA 101 Smoking Regulations SS-D Smoking Regulations Smoking regulations shall be adopted and shall include not less than the following provisions: (1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking. (2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required. (3) Smoking by patients classified as not responsible shall be prohibited. (4) The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision. K 741 8/20/22 AHCA Form 3020-0001 STATE FORM notes OBZF21 If continuation sheet, 5 of 9 Agency for Health Care Administration PRINTED: 09/08/2022 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 35960994 A. BUILDING: 05 - MAIN LIC B. WING __ (X3) DATE SURVEY COMPLETED 07/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENRIDGE ON PALMER RANCH INC. 7333 SCOTLAND WAY SARASOTA, FL 34238 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE

K 741 Continued From page 5 K 741 (5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted. (6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted. 18.7.4, 19.7.4 (Note smoking tower disposal receptacles are not ashtrays) This Statute or Rule is not met as evidenced by: Based on observation and staff interview, the facility failed to comply with the smoking regulations set forth in NFPA 101. This could adversely affect all residents and staff should a fire start from discarded smoking material. The findings included: On 7/18/22 at 1:48 p.m., it was observed in the employee's smoking area, metal containers with self-closing devices were not provided. Concurrent with the observation and at the exit conference, the Maintenance Director and Administrator acknowledged the findings. Per NFPA 101 (2018 Edition) 19.7.4 (6) Class III Specific Corrective Action: No residents were adversely affected. However, corrective action was taken specific to the deficiency. On August 4, 2022 the Maintenance Director ordered two metal containers with self-closing devices and an insulated ash bucket for disposal of metal outdoor ashtray debris. The containers were all placed at the employee smoking area on August 8, 2022 (Attachment G). Method to Assess Other Residents: No residents were adversely affected by this deficiency. Systems Review: There are no other smoking areas on campus; therefore this is the only area where the containers were required. Quality Assurance: A regularly occurring work-order was created and issued for housekeeping staff to maintain the smoking containers (Attachment H). The Maintenance Director/designee will conduct regular inspections of the smoking area to monitor AHCA Form 3020-0001 STATE FORM notes OBZF21 if continuation sheet 6 of 9 PRINTED: 09/08/2022 FORM APPROVED Agency for Health Care Administration STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 35960994 (X2) MULTIPLE CONSTRUCTION A. BUILDING: 05 - MAIN LIC B. WING __ (X3) DATE SURVEY COMPLETED 07/18/2022 NAME OF PROVIDER OR SUPPLIER GLENRIDGE ON PALMER RANCH INC. STREET ADDRESS, CITY, STATE, ZIP CODE 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) | (X5) COMPLETE DATE | |-------------------|----------------------------------------------------------------------------------------------------------------|---------------|---------------------------------------------------------------------------------------------------------------|-------------------| | K 741 | Continued From page 6 | K 741 | the disposal containers for compliance. Any issues will be immediately corrected and reported to the Administrator for reporting to the Quality Assurance Committee as part of the Life Safety Report. | | | K 918 | NFPA 99 Electrical Systems - Essential Electric<br>SS=D Syste<br>Electrical Systems - Essential Electric System<br>Maintenance and Testing<br>The generator or other alternate power source<br>and associated equipment is capable of supplying<br>service within 10 seconds. If the 10-second<br>criterion is not met during the monthly test, a<br>process shall be provided to annually confirm this<br>capability for the life safety and critical branches.<br>Maintenance and testing of the generator and<br>transfer switches are performed in accordance<br>with NFPA 110.<br>Generator sets are inspected weekly, exercised<br>under load 30 minutes 12 times a year in 20-40<br>day intervals, and exercised once every 36<br>months for 4 continuous hours. Scheduled test<br>under load conditions include a complete<br>simulated cold start and automatic or manual<br>transfer of all EES loads, and are conducted by<br>competent personnel. Maintenance and testing of<br>stored energy power sources (Type 3 EES) are in<br>accordance with NFPA 111. Main and feeder<br>circuit breakers are inspected annually, and a<br>program for periodically exercising the<br>components is established according to<br>manufacturer requirements. Written records of<br>maintenance and testing are maintained and<br>readily available. EES electrical panels and<br>circuits are marked and readily identifiable.<br>Minimizing the possibility of damage of the | K 918 | the disposal containers for compliance. Any issues will be immediately corrected and reported to the Administrator for reporting to the Quality Assurance Committee as part of the Life Safety Report. | 8/20/22 | AHCA Form 3020-0001 STATE FORM notes OBZF21 If continuation sheet, 7 of 9 Agency for Health Care Administration PRINTED: 09/08/2022 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: 05 - MAIN LIC B. WING _ (X3) DATE SURVEY COMPLETED 35960994 07/18/2022 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 918 Continued From page 7 K 918 emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Statute or Rule is not met as evidenced by: Based on record review and staff interview, the facility failed to provide evidence of routine generator maintenance based on the manufacturer's recommendations and in accordance with NFPA 101. This could adversely affect all staff and patients during a power disruption should the system fail. Findings included: On 7/18/22 between 9:00 a.m. and 12:30 p.m., during the facility record review with the Maintenance Director, the documentation for the weekly and monthly generator inspection was observed. The documentation revealed that the monthly 30 minute load test and battery conductance test was not being performed. Concurrent with the observation and at the exit conference the Maintenance Director and Administrator acknowledged the findings. Per NFPA 101 (2018 Edition) 9.1.3.1 Per NFPA 110 (2018 Edition) 8.1.1(1-4), 8.3.6.1, 8.4.2 Class III Specific Corrective Action: No residents were adversely affected. However, corrective actions was taken specific to the deficiency. On July 9, 2022 the Maintenance Director ordered a new battery tester that performs conductance tests on batteries (Attachment I). On July 22, 2022 a conductance test was performed on each battery with good results (Attachment J). The monthly 30-minute load test log was modified to record all required information during load test (Attachment K) and a 30-minute load test was successfully conducted on July 22, 2022 (Attachments K, L-1, & L-2). Method to Assess Other Residents: No residents were adversely affected by this deficiency. Systems Review: A recurring work order was created and issued for the load test and battery conductance test to be completed each month and results documented as required (Attachment M). Quality Assurance: The log for monthly generator load test and battery conductance test reports will be maintained by the Maintenance Director and a copy of the log and conductance reports will be forwarded to the Administrator. The Maintenance AHCA Form 3020-0001 STATE FORM notes OBZF21 if continuation sheet, 8 of 9 Agency for Health Care Administration PRINTED: 09/08/2022 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: 05 - MAIN LIC B. WING _ (X3) DATE SURVEY COMPLETED 35960994 07/18/2022 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 918 Continued From page 8 K 918 Director and Administrator will monitor the logs for compliance. Any issues will be reported by the Administrator to the Quality Assurance Committee as part of the Life Safety Report. AHCA Form 3020-0001 STATE FORM OBZF21 if continuation sheet, 9 of 9 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 09/08/2022 CENTERS FOR MEDICARE & MEDICAID SERVICES FORM APPROVED OMB NO. 0938-0391 REPORT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER: A. BUILDING (X3) DATE SURVEY COMPLETED 106063 B. WING 07/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENRIDGE ON PALMER RANCH INC. 7333 SCOTLAND WAY SARASOTA, FL 34238 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID (X5) PREFIX TAG (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX PROVIDER'S PLAN OF CORRECTION TAG (EACH CORRECTIVE ACTION SHOULD BE COMPLETION REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY)

E 000 Initial Comments

E 000 During the fire and life safety recertification survey conducted on 7/6/22 at Glenridge on Palmer Ranch, Inc., a skilled nursing facility, Emergency Preparedness regulations were reviewed. Glenridge on Palmer Ranch, Inc., is in compliance with Code of Federal Regulations (CFR) 42, Section 483.73, Emergency Preparedness Requirement for Long-Term Care (LTC) Facilities. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Electronically Signed 08/11/2022 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 of survey 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: O8ZF21 Facility ID: 35960994 If continuation sheet Page 1 of 1 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 09/08/2022 CENTERS FOR MEDICARE & MEDICAID SERVICES FORM APPROVED OMB NO. 0938-0391 SUMMARY OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING 01 - MAIN FED (X3) DATE SURVEY COMPLETED 106063 B. WING 07/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GLENRIDGE ON PALMER RANCH INC. 7333 SCOTLAND WAY SARASOTA, FL 34238 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID (X5) PREFIX PREFIX TAG (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG PROVIDER'S PLAN OF CORRECTION REGULATORY OR LSC IDENTIFYING INFORMATION) (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETION DATE

K 000 INITIAL COMMENTS

K 000 An unannounced Fire & Life Safety recertification survey was conducted on 7/18/22 at Glenridge on Palmer Ranch, a nursing home in Sarasota, Florida. Glenridge on Palmer Ranch is not in compliance with 42 CFR 483.90 (a) and National Fire Protection Association (NFPA) 101 (2012 edition), NFPA 99 (2012) requirements for nursing homes. Initial Plan Review: 2003 Existing NFPA 220 Construction Type: II (111) Number of beds: 59 Census: 48 The following is description of the noncompliance.

K 291 Emergency Lighting SS=D CFR(s): NFPA 101

K 291 8/20/22 Emergency Lighting Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9. 18.2.9.1, 19.2.9.1. This REQUIREMENT is not met as evidenced by: Based on facility tour and interview with the Maintenance Director, the facility failed to install battery back-up emergency lighting as required by NFPA 110. Battery back-up emergency lighting is required to insure the safety of building occupants in the event of power failure. Findings included: On 7/18/22 1:50 PM, while touring the facility with the Maintenance Director, it was observed in the enclosed generator room, a battery back-up Specific Corrective Action: No residents were adversely affected. However, corrective action was taken specific to the deficiency. On July 22, 2022 Sunshine Electrical installed the 1.5-hour duration battery back-up emergency light fixture in the emergency generator enclosure (Attachment A). The emergency light was tested on August 8, 2022 for 1.5-hour duration with no issues(Attachment B). LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Electronically Signed 08/11/2022 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: O8ZF21 Facility ID: 35960994 If continuation sheet Page 1 of 9 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PRINTED: 09/08/2022 FORM APPROVED OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 106063 (X2) MULTIPLE CONSTRUCTION A. BUILDING 01 - MAIN FED (X3) DATE SURVEY COMPLETED 07/18/2022 NAME OF PROVIDER OR SUPPLIER GLENRIDGE ON PALMER RANCH INC. STREET ADDRESS, CITY, STATE, ZIP CODE 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) (X5) COMPLETION DATE

K 291 Continued From page 1 emergency light was not provided. The Maintenance Director was unaware that one had not been installed. Concurrent with the observation and at the exit conference the Maintenance Director and Administrator acknowledged the findings. Per NFPA 101 (2012 edition) 9.1.3.1 and NFPA 110 (2016 Edition) 7.3.1

K 291 Method to Assess Other Residents: No residents were adversely affected by this deficiency. Systems Review: A work order was issued to check and test all enclosures(including emergency generator enclosure) requiring 7.9., 18.2.9.1, & 19.2.9.1. All were tested on August 8, 2022 and passed (Attachment B). Quality Assurance: All enclosures requiring battery back-up emergency lighting will be checked and tested as required. Any identified issues will be reported to the Maintenance Director and a work order completed for repair. Maintenance Director will report all issues to the Administrator who will report to the Quality Assurance Committee as part of the Life Safety report.

K 324 Cooking Facilities SS=D CFR(s): NFPA 101 Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or

K 324 8/20/22 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O8ZF21 Facility ID: 35960994 If continuation sheet Page 2 of 9 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 09/08/2022 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 106063 (X2) MULTIPLE CONSTRUCTION A. BUILDING 01 - MAIN FED (X3) DATE SURVEY COMPLETED 07/18/2022 NAME OF PROVIDER OR SUPPLIER GLENRIDGE ON PALMER RANCH INC. STREET ADDRESS, CITY, STATE, ZIP CODE 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) (X5) COMPLETION DATE

K 324 Continued From page 2 * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2 This REQUIREMENT is not met as evidenced by: Based on record review and staff interview, the facility failed to maintain the commercial cooking hood in accordance with National Fire Protection Association (NFPA) 96. This in the event of a cooking fire could affect all the occupants of the smoke compartment. The findings included: On 7/18/22 between 9:00 a.m. and 12:30 p.m., during record review, a current commercial cooking hood semi-annual inspection could not be produced. The last inspection documented was 3/23/21. Concurrent with the observation and at the exit conference, the Maintenance Director and Administrator acknowledged the findings. Per NFPA 101 (2012 Edition) 19.3.2.5, 9.2.3 Per NFPA 96 (2011 Edition) 11.2.1

K 324 Specific Corrective Action: No residents were adversely affected. However, corrective action was taken specific to the deficiency. Documentation of the previous two semi-annual hood inspections (since the 3/23/2021 inspection noted in the statement of deficiencies), September 22, 2021 (Attachment C) and March 10, 2022 (Attachment D) is attached. Method to Assess Other Residents: No residents were adversely affected by this deficiency. Systems Review: Cooking hood inspection remains on a semi-annual schedule. Next inspection is scheduled for September 6, 2022. Documentation of inspections will be forwarded to the Administrator and maintained by the Life Safety Director and will be readily available for review. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0BZF21 Facility ID: 35960994 If continuation sheet Page 3 of 9 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 09/08/2022 FORM APPROVED OMB NO. 0938-0391 SUMMARY OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING 01 - MAIN FED (X3) DATE SURVEY COMPLETED 106063 B. WING 07/18/2022 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) (X5) COMPLETION DATE

K 324 Continued From page 3

K 324 Quality Assurance: Administrator will conduct regular audits of documentation related to the semi-annual hood inspections to ensure compliance and the documents are readily available for review. Audit results will be reported in the Quality Assurance meeting as part of the Life Safety report.

K 353 Sprinkler System - Maintenance and Testing SS=F CFR(s): NFPA 101

K 353 8/20/22 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked b) Who provided system test c) Water system supply source Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This REQUIREMENT is not met as evidenced by: Based on record review and staff interview, the facility failed to maintain the automatic fire sprinkler system (AFSS) in accordance with NFPA 101. This in the event of fire this could reduce the reliability of the system and jeopardize the safety of the occupants in the facility. Specific Corrective Action: No residents were adversely affected. However, corrective action was taken specific to the deficiency. A copy of the 5-year hydrostatic test on the FDC, completed on August 12, 2021, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OBZF21 Facility ID: 35960994 If continuation sheet Page 4 of 9 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 09/08/2022 FORM APPROVED OMB NO. 0938-0391 SUMMARY OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 106063 (X2) MULTIPLE CONSTRUCTION A. BUILDING 01 - MAIN FED (X3) DATE SURVEY COMPLETED 07/18/2022 NAME OF PROVIDER OR SUPPLIER GLENRIDGE ON PALMER RANCH INC. STREET ADDRESS, CITY, STATE, ZIP CODE 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) (X5) COMPLETION DATE

K 353 Continued From page 4

K 353 The findings included: On 7/18/22 between 9:00 a.m. and 12:30 p.m. during record review of the sprinkler inspection records, it was revealed that the facility failed to provide a 5-year hydrostatic test on the FDC as well as the 5-year internal inspection of the backflow system to verify all components are unobstructed and operate correctly, move freely and are in good working condition. Concurrent with the observation and at the exit conference, the Maintenance Director and Administrator acknowledged the findings. per NFPA 101 (2012 Edition) 9.7.5, 9.7.8 per NFPA 25 (2014 Edition) 13.6.1.4, 13.7.4 was obtained (Attachment E). The 5-year internal inspection of the backflow system was completed on August 10, 2022 (Attachments F-1 & F-2). Method to Assess Other Residents: No residents were adversely affected by this deficiency. Systems Review: The 5-year hydrostatic test on the FDC and the 5-year internal inspection of the backflow system remain on a regular schedule. Next inspection of the FDC is due in 2026 and the next inspection of the backflow system is due in 2027. Quality Assurance: Documentation of both inspections will be documented by the Life Safety Director and a copy forwarded to the Administrator and will be readily available for review. Administrator and Life Safety Director will monitor inspection schedule to ensure compliance and any issues will be reported to the Quality Assurance Committee as part of the Life Safety Report.

K 741 Smoking Regulations SS-D CFR(s): NFPA 101

K 741 8/20/22 Smoking Regulations Smoking regulations shall be adopted and shall include not less than the following provisions: (1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O8ZF21 Facility ID: 35960994 If continuation sheet Page 5 of 9 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES SUMMARY OF DEFICIENCIES AND PLAN OF CORRECTION PRINTED: 09/08/2022 FORM APPROVED OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING 01 - MAIN FED (X3) DATE SURVEY COMPLETED 106063 B. WING 07/18/2022 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) (X5) COMPLETION DATE

K 741 Continued From page 5 area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking. (2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required. (3) Smoking by patients classified as not responsible shall be prohibited. (4) The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision. (5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted. (6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted. 18.7.4, 19.7.4 This REQUIREMENT is not met as evidenced by: Based on observation and staff interview, the facility failed to comply with the smoking regulations set forth in NFPA 101. This could adversely affect all residents and staff should a fire start from discarded smoking material. The findings included: On 7/18/22 at 1:48 p.m., it was observed in the employee's smoking area, metal containers with self-closing devices were not provided. Concurrent with the observation and at the exit conference, the Maintenance Director and Administrator acknowledged the findings. Per NFPA 101 (2012 Edition) 19.7.4 (6)

K 741 Specific Corrective Action: No residents were adversely affected.. However, corrective action was taken specific to the deficiency. On August 4, 2022 the Maintenance Director ordered two metal containers with self-closing devices and an insulated ash bucket for disposal of metal outdoor ashtray debris. The containers were all placed at the employee smoking area on August 8, 2022 (Attachment G). Method to Assess Other Residents: No residents were adversely affected by this deficiency. Systems Review: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OZBF21 Facility ID: 35960994 If continuation sheet Page 6 of 9 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 09/08/2022 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING 01 - MAIN FED (X3) DATE SURVEY COMPLETED 106063 B. WING 07/18/2022 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?) (X5) COMPLETION DATE

K 741 Continued From page 6

K 741 There are no other smoking areas on campus; therefore this is the only area where the containers were required. Quality Assurance: A regularly occurring work-order was created and issued for housekeeping staff to maintain the smoking containers (Attachment H). The Maintenance Director/designee will conduct regular inspections of the smoking area to monitor the disposal containers for compliance. Any issues will be immediately corrected and reported to the Administrator for reporting to the Quality Assurance Committee as part of the Life Safety Report.

K 918 Electrical Systems - Essential Electric Syste SS=F CFR(s): NFPA 101

K 918 8/20/22 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OBZF21 Facility ID: 35960994 If continuation sheet Page 7 of 9 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 09/08/2022 FORM APPROVED OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 106063 (X2) MULTIPLE CONSTRUCTION A. BUILDING 01 - MAIN FED (X3) DATE SURVEY COMPLETED 07/18/2022 NAME OF PROVIDER OR SUPPLIER GLENRIDGE ON PALMER RANCH INC. STREET ADDRESS, CITY, STATE, ZIP CODE 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) (X5) COMPLETION DATE

K 918 Continued From page 7 competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This REQUIREMENT is not met as evidenced by: Based on record review and staff interview, the facility failed to provide evidence of routine generator maintenance based on the manufacturer’s recommendations and in accordance with NFPA 101. This could adversely affect all staff and patients during a power disruption should the system fail. Findings included: On 7/18/22 between 9:00 a.m. and 12:30 p.m., during the facility record review with the Maintenance Director, the documentation for the weekly and monthly generator inspection was observed. The documentation revealed that the monthly 30-minute load test and battery conductance test was not being performed. Concurrent with the observation and at the exit conference the Maintenance Director and Administrator acknowledged the findings.

K 918 Specific Corrective Action: No residents were adversely affected. However, corrective actions was taken specific to the deficiency. On July 9, 2022 the Maintenance Director ordered a new battery tester that performs conductance tests on batteries (Attachment I). On July 22, 2022 a conductance test was performed on each battery with good results (Attachment J). The monthly 30-minute load test log was modified to record all required information during load test (Attachment K) and a 30-minute load test was successfully conducted on July 22, 2022 (Attachments K, L-1, & L-2). Method to Assess Other Residents: No residents were adversely affected by this deficiency. Systems Review: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O8ZF21 Facility ID: 35960994 If continuation sheet Page 8 of 9 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 09/08/2022 CENTERS FOR MEDICARE & MEDICAID SERVICES FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING 01 - MAIN FED (X3) DATE SURVEY COMPLETED 07/18/2022 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) (X5) COMPLETION DATE

K 918 Continued From page 8 K 918 A recurring work order was created and issued for the load test and battery conductance test to be completed each month and results documented as required (Attachment M). Quality Assurance: The log for monthly generator load test and battery conductance test reports will be maintained by the Maintenance Director and a copy of the log and conductance reports will be forwarded to the Administrator. The Maintenance Director and Administrator will monitor the logs for compliance. Any issues will be reported by the Administrator to the Quality Assurance Committee as part of the Life Safety Report. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: OBZF21 Facility ID: 35960994 If continuation sheet Page 9 of 9