Palm Garden of Clearwater

Inspectors wroteBased on interviews and record review, the facility failed to honor the Advanced Directive for one resident (#1) out of three residents sampled. On 05/14/2026, facility staff initiated Cardio-Pulmonary Resuscitation (CPR), including cardiac compressions (use of hands to push down hard and fast to manually pump blood through the heart), when Resident #1 was found unresponsive. The resident had a physician order for Do Not Resuscitate (DNR), dated 06/13/2025. Cardiopulmonary Resuscitation was provided to Resident #1 for approximately nine minutes. Failure to honor the resident's wishes caused unnecessary physical and psychosocial harm and denied Resident #1 a peaceful death. The survey team verified the facility's corrective actions to correct the noncompliance for F578 and found the facility to be in compliance as of 5/18/26, prior to the survey visitFindings included: [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure nursing staff were competent in the identification of code status for one resident (#1) out of three residents sampled. On 05/14/2026, facility staff initiated Cardio-Pulmonary Resuscitation (CPR), including cardiac compressions (use of hands to push down hard and fast to manually pump blood through the heart), when Resident #1 was found unresponsive. The resident had a physician order for Do Not Resuscitate (DNR), dated 06/13/2025. Cardiopulmonary Resuscitation was provided to Resident #1 for approximately nine minutes. Failure to honor the resident's wishes caused unnecessary physical and psychosocial harm and denied Resident #1 a peaceful death. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure staff followed care plan interventions and perform accurate assessments on residents related to bed mobility assistance for three residents (#5, #6, and #7) out of three residents sampled. On 07/25/2025 Staff A, Certified Nursing Assistant (CNA), independently rolled Resident #5 onto her side in bed to perform incontinence care. Staff A, CNA left Resident #5 unattended in bed to collect supplies. Resident #5 fell out of the bed while unattended and suffered a right hip fracture which required a transfer to a higher level of care and surgical repair. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to residents and resulted in the determination of Immediate Jeopardy on 08/07/2025. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to prevent a fall with serious injury for one resident (#5) out of three residents sampled for accidents. On 07/25/2025 Staff A, Certified Nursing Assistant (CNA), independently rolled Resident #5 onto her side in bed to perform incontinence care. Staff A, CNA left Resident #5 unattended in bed to collect supplies. Resident #5 fell out of the bed while unattended and suffered a right hip fracture which required a transfer to a higher level of care and surgical repair. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to residents and resulted in the determination of Immediate Jeopardy on 08/07/2025. [...]

Inspectors wroteBased on interview and record reviews, the facility failed to ensure Preadmission Screening and Resident Review (PASRR) assessments were accurate for twelve residents (#1, #126, #44, #97, #71, #119, #116, #60, #90, and #39) out of 32 residents sampled.

Inspectors wroteBased on interviews, observations, and record review, the facility failed to ensure sufficient staffing in order to provide timely meal service to residents on two units (B & D units) of four units in the facility.

Inspectors wroteBased on observations, record review, and interviews, the facility did not follow professional standards for food service safety in the kitchen and one of four nourishment rooms.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to maintain resident dignity related to 1.) wearing of plastic informational bands for ten residents (#30, #50, #72, #33, #90, #121, #45, #34, #123, and #81) of sixty-seven sampled residents and 2.) failed to ensure a urinary catheter bag with contents was positioned in a private manner during two of four days observed (2/3/2025 and 2/4/2025), for one resident (#123) of fourteen residents who utilized indwelling catheters.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to follow physician orders and provide wound care in accordance with professional standards of practice for three residents (#5, #138, and #266) of five residents reviewed for surgical and non-surgical wound care.

Inspectors wroteBased on interviews, and record review, the facility failed to offer a nourishing snack at bedtime for five (#268, #266, #269, #39, and #270) out of six residents sampled for dining.

Inspectors wroteBased on observations, interviews, and record review, the facility did not ensure prompt efforts were made to resolve grievance for two residents (#109 and #268) out of three residents sampled for grievances.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure care to prevent pressure ulcers was received in accordance with professional standards of practice for one resident (#30) of five residents sampled for skin conditions.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to follow contracture maintenance programs for one resident (#81) of sixty-seven sampled residents. It was found the resident was not assisted with donning and doffing of their splint device during four of four days observed (2/3/2025, 2/4/2025, 2/5/2025, and 2/6/2025).

Inspectors wroteBased on interview and record review, the facility failed to ensure the documentation was accurate in the medical record for three of three sampled residents (#1, #2, #3).

Inspectors wroteBased on interview and record review, the facility failed to report an event that led to transfer to a higher level of care within the specified timeframe of the allegation for one of one sampled residents (#1).

Inspectors wroteBased on interview and record review, the facility failed to ensure the Comprehensive Patient-Centered Care Plan was developed and accurate related to NPO (nothing by mouth) status and behaviors for one of three sampled residents (#1).

Inspectors wroteBased on observations, interview, and policy review, the facility failed to label and date opened food and maintain a clean, sanitary kitchen in accordance with professional standards for food service safety.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to implement an effective Infection Control program related to the unsanitary environment of the laundry room related to personal food items and belongings sitting on same folding counter as resident linen, failed to ensure two (Staff H and J) direct care staff members had fingernails that were per Centers of Disease Control and Prevention guidelines were of an appropriate length, and failed to ensure Seven (Residents #86, #119, #23, #112, #37, #58, and #42) out of eight residents receiving oxygen therapies.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure two (Residents #43 and #86) of 46 sampled residents were assessed for self-administration of medications.

Inspectors wroteBased on interviews, observations, and record reviews, the facility failed to implement an effective grievance program for two (Residents #515 and #43) of 47 sampled residents related to the operation of in-room telephone service and missing property.

Inspectors wroteBased on observations, interviews, and record review, the facility did not ensure fall interventions were implemented per care plan for one (Resident #144) of eight residents reviewed for falls.

Inspectors wroteBased on Observations, interview, and record review, the facility failed to provide adequate supervision to prevent falls for three (Residents #98, #111, and #514) of eight residents sampled for falls.

Inspectors wroteBased on observation, staff interview, and medical record review, the facility failed to ensure fall risk care planned interventions were followed related to call light placement, for two residents (#100 and #114) of forty sampled residents. It was determined that during three of four days observed, both residents were found with call light buttons not placed within their reach, while in their rooms and in bed.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that documentation in the medical record for one resident (#119) out of 40 sampled residents was accurate related to the application of a neck collar for positioning.

Inspectors wroteBased on observations, staff interview and facility record review, the facility failed to ensure, 1. two (A wing and B wing) of three self-making ice machines and the internal ice-storage chests were clean and free from bio growth/debris and a gelatinous substance and 2. sanitary maintenance of a shower chair in a shared resident bathroom (#315) on one nursing unit (South) of two nursing units for two of two days observed.