Inspection·April 2, 2024

K 000 An unannounced Fire & Life Safety recertification survey was conducted on 4/2/24 at Glenridge on Palmer Ranch, a skilled nursing facility in Sarasota, Florida. Glenridge on Palmer Ranch is not in compliance with the Code of Federal Regulations (CFR) 42, Section 483.90(a)(b), Physical Environment Requirements for Long-Term Care Facilities and the National Fire Protection Association (NFPA) 101 (2012 edition) Life Safety Code. Initial Plan Review: 2003 Existing NFPA 220 Construction Type: II (111) Number of beds: 59 The following is the description of the noncompliance.

K 324 Cooking Facilities SS=D CFR(s): NFPA 101

K 324 5/4/24 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 LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE Electronically Signed TITLE 04/25/2024 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:8FA521 Facility ID: 35960994 If continuation sheet Page 1 of 8 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 04/29/2024 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING 01 - MAIN FED 106063 B. WING 04/02/2024 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 (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) PREFIX TAG PREFIX TAG COMPLETION DATE

K 324 Continued From page 1 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 observations, and staff interview with the Maintenance Director, it was revealed that the facility failed to maintain the commercial cooking equipment as required per NFPA 96. The findings included: On 4/2/24 between 12:30 p.m. and 4:00 p.m. while touring the kitchen with the Maintenance Director: 1. The deep fryer was positioned at the far right of the kitchen hood, extending 1 inch past the end. 2. 2 of the 3 tethers were found to be unfastened from the gas fired appliances. An interview was conducted with the Maintenance Director concurrent with the observations confirming the findings. per NFPA 101 (2012 Edition) 19.3.2.5.1, 9.2.2, 9.2.3 per NFPA 96 (2011 Edition) 10.1.2 per NFPA 54 (2012 Edition) 9.6.1.2

K 324 Specific Corrective Action: No residents were adversely affected. However corrective action was taken specific to the deficiency. On April 3, 2024, the Maintenance Director issued a work order to check all gas appliance tethers and location of fryer under hood. Work order required tech to refasten any tethers not connected to the gas appliances and add a wheel chock to the deep fryer to maintain it's proper location under the hood. This corrective action was completed on April 3, 2024. (See Attachments A, B, & C) Method to Assess Other Residents: No residents were adversely affected by this deficiency. Systems Review: All equipment tethers and equipment placement checked to verify compliance. Additionally, on April 19, 2024, the Kitchen Manager/Executive Chef conducted an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:8FA521 Facility ID: 35960994 If continuation sheet Page 2 of 8 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 04/29/2024 CENTERS FOR MEDICARE & MEDICAID SERVICES FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER: A. BUILDING 01 - MAIN FED (X3) DATE SURVEY COMPLETED 106063 B. WING 04/02/2024 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 PROVIDER'S PLAN OF CORRECTION (X5) PREFIX TAG (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX TAG (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE COMPLETION REGULATORY OR LSC IDENTIFYING INFORMATION) DEFICIENCY) DATE

K 324 Continued From page 2

K 324 in-service with all kitchen staff regarding tether attachment requirements and gas appliance position under cooking hood. (See Attachment D) Quality Assurance: Kitchen Manager/Executive Chef will conduct routine inspections to ensure proper equipment placement and required tethering (except when cleaning or repairing) and report findings to Administrator. Administrator will report inspection findings to the Quality Assurance Committee as part of the Life Safety report.

K 521 5/4/24

K 521 HVAC SS=F CFR(s): NFPA 101 HVAC Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications. 18.5.2.1, 19.5.2.1, 9.2 This REQUIREMENT is not met as evidenced by: Based on observations and staff interview with the Maintenance Director, the facility failed to maintain the exhaust ventilation system in accordance with National Fire Protection Association (NFPA) 101. This can adversely affect all 39 residents as well as staff and visitors due to improper ventilation and air exchange.

K521 Specific Corrective Action: No residents were adversely affected. However, corrective action was taken specific to the deficiency. On April 2, 2024, the Maintenance Director issued a work order to check and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:8FA521 Facility ID: 35960994 If continuation sheet Page 3 of 8 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 04/29/2024 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 106063 B. WING 04/02/2024 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 521 Continued From page 3 The findings included: On 4/2/24 between 12:30 p.m. and 4:00 p.m. during the facility tour with the Maintenance Director, random ceiling exhaust inlets were tested for airflow. The following was observed. 1. Resident rooms off the Red Hall were found non-operational. 2. Resident rooms off the Green Hall were found non-operational. 3. Resident rooms off the Yellow Hall were found non-operational. An interview was conducted with the Maintenance Director concurrent with the observations confirming the findings. per NFPA 101 (2012 Edition) 19.5.2.1, 9.2.2 per NFPA 91 (2010 Edition) 10.2, 10.6.1

K 521 repair exhaust fans on Red, Blue, and Yellow hills (Attachment E). Glenridge Technicians located faulty rib relays and replaced on April 2, 2024 (Attachment E - highlighted portion in Completion Notes) Method to Assess Other Residents: No residents were adversely affected by this deficiency. Systems Review: On same work order on April 2, 2024 , Maintenance Director also requested check of Green hall fan to verify operational. Green Half fan was found to be 100% operational. Red, Blue and Yellow hall fans were all verified for proper functioning after replacement of faulty rib relays. All patient rooms were also checked and verified exhaust working as required (Attachments F, G & H). All exhaust fans were 100% operational by 3:30 pm on April 2, 2024. Quality Assurance: The Maintenance Director modified the current monthly preventive maintenance inspection work order for all Carroll Center exhaust fans to now be checked bi-weekly (Attachments I, J, K & L). Maintenance Director will report any issues with exhaust fans to the Administrator who will report to the Quality Assurance Committee as part of the Life Safety report.

K 761 Maintenance, Inspection & Testing - Doors SS=D

K 761 5/4/24 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8FA521 Facility ID: 35960994 If continuation sheet Page 4 of 8 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES SUMMARY OF DEFICIENCIES AND PLAN OF CORRECTION PRINTED: 04/29/2024 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 04/02/2024 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 (X5) SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG (X6) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X8) COMPLETION DATE

K 761 Continued From page 4 CFR(s): NFPA 101 Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. 19.7.6, 8.3.3.1 (LSC) 5.2, 5.2.3 (2010 NFPA 80) This REQUIREMENT is not met as evidenced by: Based on facility record review and interview with Maintenance Director, the facility failed to maintain fire dampers in accordance with NFPA 101. Failure to maintain dividing fire barriers may result in fire spreading to other compartments and endangering building occupants. The findings included: On 4/2/24 between 9:30 a.m. and 12:30 p.m. during record review, a fire damper inspection report could not be produced. On 4/3/24 The Maintenance Director submitted a report dated 2/9/22. 1 Damper was found to be nonfunctioning. Repair documentation was submitted dated 8/3/22 with the following findings: "No power or fire alarm wires pulled to damper". Documentation shows repairs have been made. Documentation for acceptance testing and re-inspection of the fire damper could not be

K 761

K761 Specific Corrective Action: No residents were adversely affected. However, corrective action was taken specific to the deficiency. On April 19, 2024 the Maintenance Director executed a contract with Piper Fire Protection, LLC to complete the Damper Inspection and Testing (Attachment M(a) and M(b)). On Tuesday, April 23, 2024 a confirmation email was received from Piper Fire Protection confirming that the testing is scheduled for completion on Friday, April 26, 2024. (Attachment N) Method to Assess Other Residents: No residents were adversely affected by this deficiency. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:8FA521 Facility ID: 35960994 If continuation sheet Page 5 of 8 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 04/29/2024 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER: A. BUILDING 01 - MAIN FED (X3) DATE SURVEY COMPLETED 106063 B. WING NAME OF PROVIDER OR SUPPLIER GLENRIDGE ON PALMER RANCH INC. STREET ADDRESS, CITY, STATE, ZIP CODE 7333 SCOTLAND WAY SARASOTA, FL 34238 04/02/2024 (X4) ID (X5) SUMMARY STATEMENT OF DEFICIENCIES ID (X6) PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X7) COMPLETION DATE

K 761 Continued From page 5 produced. An interview was conducted with the Administrator concurrent with the observations confirming the findings. Per NFPA 101 (2012 Edition) 19.7.6, 4.6.12.1, 8.5.5.4.2 Per NFPA 80 (2010 Edition) 19.5.3, 19.5.4 Per NFPA 105 (2010 Edition) 6.6.3, 6.6.4

K 761 Systems Review: The Maintenance Director verified that all other smoke dampers have been tested and inspected/reinspected as required. Quality Assurance: The Maintenance Director will ensure that any smoke dampers that fail inspection are repaired and reinspected/retested within the required timeframe. Any smoke dampers that fail inspection, will be repaired and retested/reinspected and will be reported to the Administrator who will report to the Quality Assurance Committee as part of the Life Safety report.

K 918 Electrical Systems - Essential Electric Syste SS=E CFR(s): NFPA 101 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 competent personnel. Maintenance and testing of

K 918 5/4/24 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:8FA521 Facility ID: 35960994 If continuation sheet Page 6 of 8 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 04/29/2024 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 B. WING (X3) DATE SURVEY COMPLETED 04/02/2024 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 6

K 918 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 with the Maintenance Director, the facility failed to provide evidence of generator maintenance and testing in accordance with NFPA 101. Failure to maintain the generator will result in a loss of power to the facility thus endangering the residents and occupants of the facility. The findings included: On 4/2/24 between 9:30 a.m. and 12:30 p.m. during record review with the (MD) Maintenance Director, the facility failed to show documentation for the annual major inspection including oil change. When interviewed, the MD said his generator company mistakenly performed a minor inspection. On 4/2/24 at 1:05 p.m. while touring the grounds with the MD, the generator was observed. When asked if 2 sets of instruction manuals were located at the facility, the MD said he did not.

K918 Specific Corrective Action: No residents were adversely affected. However, corrective actions were taken specific to the deficiency. On April 3, 2024 the Annual Major Periodic Maintenance service was completed(See Attachments O-1 thru O-13). The facility now has two sets of manuals for the generator; one is located at the Generator and the other in the Maintenance Directors office. (See Attachments P-1 and P-2) The Maintenance Director ordered various essential spare parts for the generator and has them stored in the maintenance department. (See Attachments Q-1 and Q-2) Method to Assess Other Residents: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:8FA521 Facility ID: 35960994 If continuation sheet Page 7 of 8 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PRINTED: 04/29/2024 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 04/02/2024 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) EXECUTION DATE

K 918 Continued From page 7 K 918 When asked if a supply of essential spare parts for the generator was stored on site, the MD said no. An interview was conducted with the Maintenance Director concurrent with the observations confirming the findings. per NFPA 99 (2012 Edition) 6.4.4.1.1.1, 6.4.4.1.1.3, 6.4.4.2 per NFPA 101 (2012 Edition) 21.5.1, 9.1.3.1 per NFPA 110 (2010 Edition) 8.1, 8.2.2, 8.2.4, 8.3.4 No residents were adversely affected by this deficiency. Systems Review: Maintenance Director ensured that the order of required services for the generator are clearly tracked so all minor and major inspections are completed on time and in the correct order for Level 1 Generator servicing the Carroll Center. Quality Assurance: Maintenance Director will provide the service receipts to the Administrator and maintain documentation as the required services are completed and Administrator will report to the Quality Assurance Committee as part of the Life Safety Report. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8FA521 Facility ID: 35960994 If continuation sheet Page 8 of 8 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 04/29/2024 FORM APPROVED OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING ________ B. WING ________ (X3) DATE SURVEY COMPLETED 04/02/2024 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

E 000 Initial Comments

E 000 During the Fire & Life Safety recertification survey that was conducted on 4/2/24 at Glenridge on Palmer Ranch, a skilled nursing facility, Emergency Preparedness regulations were reviewed. Glenridge on Palmer Ranch is in compliance with the 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 04/25/2024 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:8FA521 Facility ID: 35960994 If continuation sheet Page 1 of 1 PRINTED: 04/29/2024 FORM APPROVED AGENCY FOR HEALTH CARE ADMINISTRATION 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 04/02/2024 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 An unannounced Fire & Life Safety relicensure survey was conducted on 4/2/24 at Glenridge on Palmer Ranch, a skilled nursing facility in Sarasota, Florida. This survey was completed in accordance with National Fire Protection Association (NFPA) 1 and 101 (2018 Edition) and applicable requirements of Florida State Fire Marshal's Rules and Regulations, Florida Administrative Code (F.A.C) 69A-3, F.A.C. 69A-53, F.A.C. 59A-4, and Florida Statutes (F.S.) 400 Part II, and F.S. 633.0215, adopting NFPA 1 and 101 (2018 Edition) known as the Florida Fire Prevention Code and all NFPA referenced standards and requirements adopted per NFPA 101, Chapter 2. The following is the description of the deficiencies.

K 324 NFPA 101 Cooking Facilities SS=D

K 324 5/4/24 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. Cooking facilities protected according to NFPA 96 AHCA Form 3020-0001 LABORATORY DIRECTOR OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Electronically Signed 04/25/24 STATE FORM 6809 8FA521 If continuation sheet 1 of 7 Agency for Health Care Administration PRINTED: 04/29/2024 STATEMENT OF DEFICIENCIES FORM APPROVED AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: 05 - MAIN LIC B. WING __ (X3) DATE SURVEY COMPLETED 04/02/2024 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 PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE

K 324 Continued From page 1 K 324 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 observations, and staff interview with the Maintenance Director, it was revealed that the facility failed to maintain the commercial cooking equipment as required per NFPA 96. The findings included: On 4/2/24 between 12:30 p.m. and 4:00 p.m. while touring the kitchen with the Maintenance Director: 1. The deep fryer was positioned at the far right of the kitchen hood, extending 1 inch past the end. 2. 2 of the 3 tethers were found to be unfastened from the gas fired appliances. An interview was conducted with the Maintenance Director concurrent with the observations confirming the findings. per NFPA 101 (2021 Edition) 19.3.2.5.1, 9.2.2, 9.2.3 per NFPA 96 (2017 Edition) 10.1.2 per NFPA 54 (2018 Edition) 9.6.1.4 Class III

K 324 Specific Corrective Action: No residents were adversely affected. However corrective action was taken specific to the deficiency. On April 3, 2024, the Maintenance Director issued a work order to check all gas appliance tethers and location of fryer under hood. Work order required to refasten any tethers not connected to the gas appliances and add a wheel chock to the deep fryer to maintain it's proper location under the hood. This corrective action was completed on April 3, 2024. (See Attachments A, B, & C) Method to Assess Other Residents: No residents were adversely affected by this deficiency. Systems Review: All equipment tethers and equipment placement checked to verify compliance. Additionally, on April 19, 2024, the Kitchen Manager/Executive Chef conducted an in-service with all kitchen staff regarding tether attachment requirements and gas appliance position under cooking hood. (See Attachment D) Quality Assurance: Kitchen Manager/Executive Chef will AHCA Form 3020-0001 STATE FORM notes 8FA521 if continuation sheet, 2 of 7 Agency for Health Care Administration PRINTED: 04/29/2024 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED 35960994 A. BUILDING: 05 - MAIN LIC B. WING __ 04/02/2024 NAME OF PROVIDER OR SUPPLIER GLENRIDGE ON PALMER RANCH INC. STREET ADDRESS, CITY, STATE, ZIP CODE 7333 SCOTLAND WAY SARASOTA, FL 34238 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX ID PROVIDER'S PLAN OF CORRECTION (X6) 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 DEFICIENCY) COMPLETE DATE

K 324 Continued From page 2 K 324 conduct routine inspections to ensure proper equipment placement and required tethering (except when cleaning or repairing) and report findings to Administrator. Administrator will report inspection findings to the Quality Assurance Committee as part of the Life Safety report. 5/4/24

K 521 NFPA 101 HVAC K 521 SS=F HVAC Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications. 18.5.2.1, 19.5.2.1, 9.2 This Statute or Rule is not met as evidenced by: Based on observations and staff interview with the Maintenance Director, the facility failed to maintain the exhaust ventilation system in accordance with National Fire Protection Association (NFPA) 101. This can adversely affect all 39 residents as well as staff and visitors due to improper ventilation and air exchange. The findings included: On 4/2/24 between 12:30 p.m. and 4:00 p.m. during the facility tour with the Maintenance Director, random ceiling exhaust inlets were tested for airflow. The following was observed. 1. Resident rooms off the Red Hall were found non-operational. 2. Resident rooms off the Green Hall were found non-operational. 3. Resident rooms off the Yellow Hall were found non-operational.

K521 Specific Corrective Action: No residents were adversely affected. However, corrective action was taken specific to the deficiency. On April 2, 2024, the Maintenance Director issued a work order to check and repair exhaust fans on Red, Blue, and Yellow halls (Attachment E). Glenridge Technicians located faulty rib relays and replaced on April 2, 2024 (Attachment E - highlighted portion in Completion Notes) Method to Assess Other Residents: No residents were adversely affected by this deficiency. Systems Review: AHCA Form 3020-0001 STATE FORM notes 8FA521 if continuation sheet, 3 of 7 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 04/02/2024 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 521 Continued From page 3 An interview was conducted with the Maintenance Director concurrent with the observations confirming the findings. per NFPA 101 (2021 Edition) 19.5.2.1, 9.2.2 per NFPA 91 (2020 Edition) 10.2, 10.6.1 Class III

K 521 On same work order on April 2, 2024, Maintenance Director also requested check of Green hall fan to verify operational. Red, Blue and Yellow hall fans were all verified for proper functioning after replacement of faulty nb relays. All patient rooms were also checked and verified exhaust working as required (Attachments F, G & H). All exhaust fans were 100% operational by 3:30 pm on April 2, 2024. Quality Assurance: The Maintenance Director modified the current monthly preventive maintenance inspection work order for all Carroll Center exhaust fans to now be checked bi-weekly (Attachments I, J, K, & L). Maintenance Director will report any issues with exhaust fans to the Administrator who will report to the Quality Assurance Committee as part of the Life Safety report. 5/4/24

K 761 NFPA 101 Maintenance Inspection & Testing - SS=D Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review.

K 761 AHCA Form 3020-0001 STATE FORM notes 8FA521 If continuation sheet, 4 of 7 Agency for Health Care Administration PRINTED: 04/29/2024 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 04/02/2024 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 761 Continued From page 4 K 761 19.7.6, 8.3.3.1 (NFPA 101) 5.2. 5.2.3 (NFPA 80) This Statute or Rule is not met as evidenced by: Based on facility record review and interview with Maintenance Director, the facility failed to maintain fire dampers in accordance with NFPA 101. Failure to maintain dividing other barriers may result in fire spreading to other compartments and endangering building occupants. The findings included: On 4/2/24 between 9:30 a.m. and 12:30 p.m. during record review, a fire damper inspection report could not be produced. On 4/3/24 The Maintenance Director submitted a report dated 2/9/22. 1 Damper was found to be nonfunctioning. Repair documentation was submitted dated 8/3/22 with the following findings: "No power or fire alarm wiring pulled to damper". Documentation shows repairs have been made. Documentation for acceptance testing and reinspection of the fire damper could not be produced. An interview was conducted with the Administrator concurrent with the observations confirming the findings. Per NFPA 101 (2021 Edition) 19.7.6, 4.6.12.1, 4.6.12.5, 8.5.5.4.2 Per NFPA 80 (2019 Edition) 19.6.3, 19.6.4 Per NFPA 105 (2019 Edition) 7.7.3, 7.7.4 Class III

K761 Specific Corrective Action: No residents were adversely affected. However, corrective action was taken specific to the deficiency. On April 19, 2024 the Maintenance Director executed a contract with Piper Fire Protection, LLC to complete the Damper Inspection and Testing (Attachment M(a) and M(b)). On Tuesday, April 23, 2024 a confirmation email was received from Piper Fire Protection confirming that the testing is scheduled for completion on Friday, April 26, 2024. (Attachment N) Method to Assess Other Residents: No residents were adversely affected by this deficiency. Systems Review: The Maintenance Director verified that all other smoke dampers have been tested and inspected/reinspected as required. Quality Assurance: The Maintenance Director will ensure that any smoke dampers that fail inspection are repaired and retested/reinspected within the required timeframe. Any smoke dampers that fail inspection, will be repaired and retested/reinspected and will be reported to the Administrator who will report to the Quality Assurance Committee as part of the Life Safety report. AHCA Form 3020-0001 STATE FORM notes 8FA521 if continuation sheet, 5 of 7 Agency for Health Care Administration PRINTED: 04/29/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 05 - MAIN LIC COMPLETED 35960994 B. WING __________ 04/02/2024 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 PROVIDER'S PLAN OF CORRECTION (X6) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY)

K 918 NFPA 99 Electrical Systems - Essential Electric SS=E Syste 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 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 and readily identifiable. 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 Statute or Rule is not met as evidenced by: Based on record review and staff interview with the Maintenance Director, the facility failed to

K 918 K918 5/4/24 AHCA Form 3020-0001 STATE FORM notes 8FA521 if continuation sheet 6 of 7 Agency for Health Care Administration PRINTED: 04/29/2024 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 35960994 A. BUILDING: 05 - MAIN LIC B. WING __ (X3) DATE SURVEY COMPLETED 04/02/2024 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 918 Continued From page 6 K 918 provide evidence of generator maintenance and testing in accordance with NFPA 101. Failure to maintain the generator will result in a loss of power to the facility thus endangering the residents and occupants of the facility. The findings included: On 4/2/24 between 9:30 a.m. and 12:30 p.m. during record review with the (MD) Maintenance Director, the facility failed to show documentation for the annual major inspection including oil change. When interviewed, the MD said his generator company mistakenly performed a minor inspection. On 4/2/24 at 1:05 p.m. while touring the grounds with the MD, the generator area was observed. When asked if 2 sets of instruction manuals were located at the facility, the MD said he did not. When asked if a supply of essential spare parts for the generator was stored on site, the MD said no. An interview was conducted with the Maintenance Director concurrent with the observations confirming the findings. Per NFPA 101 (2021 Edition) 21.5.1.1, 9.1.3.1 Per NFPA 110 (2019 Edition) 8.1, 8.2.2, 8.2.4, 8.5.2 Class III Specific Corrective Action: No residents were adversely affected. However, corrective actions were taken specific to the deficiency. On April 3, 2024 the Annual Major Periodic Maintenance service was completed(See Attachments O-1 thru O-13). The facility now has two sets of manuals for the generator; one is located at the Generator and the other in the Maintenance Directors office. (See Attachments P-1 and P-2) The Maintenance Director ordered various essential spare parts for the generator and has them stored in the maintenance department. (See Attachments Q-1 and Q-2) Method to Assess Other Residents: No residents were adversely affected by this deficiency. Systems Review: Maintenance Director ensured that the order of required services for the generator are clearly tracked so all minor and major inspections are completed on time and in the correct order for Level 1 Generator servicing the Carroll Center. Quality Assurance: Maintenance Director will provide the service receipts to the Administrator and maintain documentation as the required services are completed and Administrator will report to the Quality Assurance Committee as part of the Life Safety Report. AHCA Form 3020-0001 STATE FORM notes 8FA521 if continuation sheet 7 of 7