Palm Garden of Gainesville

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain complete and accurately documented medical records for 5 of 8 residents, Residents #28, #32, #62, #97, and #119 reviewed for medication management, 2 of 6 residents, Residents #99 and #111 reviewed for mood and behavior, 1 of 3 residents, Resident #103 reviewed for intravenous therapy, and 1 of 3 residents, Resident #136, reviewed for discharge.

Inspectors wroteBased on record review and interview the facility failed to ensure a recapitulation summary was documented for 1 of 3 residents, Resident #136, reviewed for discharge.

Inspectors wroteBased on observation, interview, and record reviews the facility failed to ensure accurate Minimum Data Set (MDS) assessments for 3 of 8 residents, Residents #73, #103, and #87, reviewed for MDS assessments.

Inspectors wroteBased on interviews and record review, the facility failed to comply with the development and implementation of a comprehensive care plan regarding suctioning in 1 out of 3 residents. Resident #73.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain appropriate grooming and personal hygiene for 1 of 3 residents, Resident #61, reviewed for Activities of Daily Living.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure treatment and care was provided in accordance with professional standards of practice for a central venous catheter for 1 of 3 residents, Resident #103, observed for intravenous (IV) catheter care and medication administration practices.

Inspectors wrote2) Review of Resident #62 Omnicare Consultation Report dated 4/18/2025 read, Recommendation: Please attempt a gradual dose reduction to Abilify 1 mg once daily. The consultation report did not have a physician signature, or a rationale only documented MD [Medical Doctor] refused. Review of Resident #62 physician order dated 4/17/2025 read, Aripiprazole Tablet 2 mg give 1 tablet by mouth in the morning for depression. During an interview on 5/29/2025 at 3:53 PM Medical Doctor #1 stated, [Resident #62's name] has severe depression and is doing fairly well with the medication. After talking to the resident, we decided to keep the medication. Sometimes the facility requires a rationale, but it is typically more complicated. Usually, the nurses will drop the recommendation in my book, and I will review them. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principle for 1 of 3 hallways reviewed for secured medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain appropriate infection prevention and control practices during medication administration for 2 of 15 residents, Residents #78 and #338) reviewed for medication administration practices, and failed to ensure appropriate infection control barriers were applied for residents with orders for isolation for 1 of 2 residents, Resident #129, reviewed for infection control.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident records were complete and accurate for 1 of 3 residents, Resident #2, reviewed for wound care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the possible spread of infection when failing to perform hand hygiene or use appropriate personal protective equipment (PPE) when performing care for 1 (Resident #1) of 3 residents on Enhanced Barrier Precautions.

Inspectors wroteBased on observation and interview, the facility failed to provide a clean and homelike environment.

Inspectors wroteBased on interview and record review, the facility failed to provide Medicare coverage and liability notice to resident representative for 1 of 3 residents reviewed for notice of Medicare non coverage, Resident #1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was safely stored, covered, labeled, and failed to ensure the equipment was cleaned in the areas of the kitchen and nourishment rooms.

Inspectors wroteBased on record review and interview, the facility failed to ensure that resident assessments were transmitted in a timely manner for 2 of 3 residents sampled, Residents #44 and #46.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide surgical wound care and treatment in accordance with professional standards of practice for 1 of 4 residents reviewed for skin conditions, Resident #77 (Photographic evidence obtained).

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer oxygen per physician order and according to professional standards of practice for 2 of 3 residents reviewed for respiratory care, Residents #36 and #112.

Inspectors wroteBased on observation and interview, the facility failed to ensure nurse staffing information was posted daily.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were securely stored in 1 of 3 residential units, Unit 300.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain accurate and complete medical records for 1 of 2 residents reviewed for insulin administration out of a total of 6 residents reviewed for medications, Resident #104.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene during medication administration to help prevent the possible transmission of infection and communicable diseases in 3 of 6 observations for medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was safely stored in the kitchen and dry storage areas, and the food was distributed in accordance with professional standards.

Inspectors wrote5. During an observation on 10/4/2022 at 9:15 AM, Resident #27 was in her room, with the nebulizer mask lying unbagged on her bedside table. During an interview on 10/4/2022 at 9:15 AM, Resident #27 stated the unbagged mask was part of her breathing treatment machine. On 10/5/2022 at 8:08 AM, Resident #27 was observed in her room, with the nebulizer mask lying unbagged on her bedside table. Review of Resident #27's Medication Administration Record (MAR) dated for the period from 10/1/2022 through 10/31/2022 showed the resident had received Ipratropium-Albuterol Solution 0.5-2.5 (3) milligrams/3 milliliters for hypercapnia at 9:00 AM, 2:00 PM and 9:00 PM on 10/3/2022 and 10/4/2022. During an interview on 10/6/2022 at 7:44 AM, Staff B, LPN, stated Resident #27's nebulizer mask should be cleaned and bagged after each use. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the residents received urostomy site dressing care and services in accordance with professional standards of practice for 1 of 9 residents who needed dressing changes, Resident #89.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion for 1 of 16 residents with contractures, Resident #114.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was not 5% or greater. The medication error rate was 28.57%.