Inspection·May 15, 2024

DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 05/29/2024 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 R 05/15/2024 106063 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 (X5) SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG (X7) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X8) COMPLETION DATE [K 000] INITIAL COMMENTS [K 000] A Fire & Life Safety follow-up by desk review was conducted on 5/15/24 for Glenridge on Palmer Ranch, a skilled nursing facility in Sarasota, Florida. The follow-up was in response to the Annual Fire & Life Safety recertification survey completed on 4/2/24. Based on the facility's plan of correction and supporting documentation, Glenridge on Palmer Ranch is 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 as of 5/4/24. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Electronically Signed 05/28/2024 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:8FA522 Facility ID: 35960994 If continuation sheet Page 1 of 1 Agency for Health Care Administration PRINTED: 05/29/2024 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 R 05/15/2024 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 000) INITIAL COMMENTS (K 000) A Fire & Life Safety follow-up by desk review was conducted on 5/15/24 for Glenridge on Palmer Ranch, a skilled nursing facility in Sarasota, Florida. The follow-up was in response to the Annual Fire & Life Safety relicensure survey completed on 4/2/24. Based on the facility's plan of correction and supporting documentation, the deficiencies were corrected as of 5/4/24. The 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. AHCA Form 3020-0001 LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X8) DATE Electronically Signed 05/28/24 STATE FORM 6809 8FA522 If continuation sheet 1 of 1