Palm Garden of Jacksonville

Inspectors wroteBased on observations, interviews and a review of policies and procedures, the facility failed to provide food at a safe and appetizing temperature for residents on one of four items on the holding line in the main kitchen and for four of four items on a test tray provided after the last resident received their tray.

Inspectors wroteBased on observations, interviews, and a review of the facility's policies and procedures, the facility failed to ensure food was safely stored, labeled, or discarded for two (open, unlabeled beef base paste and spoiled green peppers) of six items in the walk-in cooler and for two (uncovered cake and open, unlabeled jelly) of four items in the main kitchen. Unsafe food handling practices represent a potential source of pathogen exposure.

Inspectors wroteBased on interviews and record review, the facility failed to properly document a discharge plan for two (Residents #11 and #118) of six residents reviewed for transfer/discharge. When the facility transfers or discharges a resident, the facility must ensure that the transfer or discharge is documented in the resident's medical record.

Inspectors wroteBased on interviews, record review, and a review of the facility's policies and procedures, the facility failed to provide necessary treatment and services, consistent with professional standards of practice to promote healing and prevent infection for one (Resident #101) of two residents reviewed for wound care from a total survey sample of 46 residents.

Inspectors wroteBased on observations, record review, interviews, and a review of facility policies and procedures, the facility failed to 1) Ensure medications were properly labeled for one resident (#110) to facilitate safe medication administration, and 2) Ensure medications were properly stored for one resident (#97) to prevent unauthorized access to medications, out of five residents reviewed for medication storage/labeling, from a total survey sample of 46 residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to obtain emergency dental care to meet the needs of one (Resident #101) of 46 residents in the total survey sample who was experiencing dental pain.

Inspectors wroteBased on record review and interviews, the facility failed to identify and provide needed care and services in accordance with professional standards of practice, by failing to monitor blood glucose levels for one (Resident #3) of two residents reviewed for blood glucose monitoring.

Inspectors wroteBased on record reviews, interviews, and observations, the facility failed to 1) Ensure that the physician/physician representative reviewed the resident's total program of care, including medications and treatments, and 2) Sign and date all orders for one (Resident #3) of two residents reviewed for blood glucose monitoring.

Inspectors wroteBased on observation, staff interview, and facility policy and procedure review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety, by failing to 1) Ensure sanitary storage of bulk food items, 2) Ensure baking pans were air dried, and 3) Ensure that the ice and water dispensing machine used for residents' drinks in the nourishment room, was clean and sanitary.

Inspectors wroteBased on observation, facility document review, staff interview, manufacturer's specifications review, and facility policy and procedure review, the facility failed to ensure essential mechanical equipment in the kitchen was maintained in a safe operating condition, as evidenced by the dish machine not functioning according to manufacturer's specifications to ensure dishware was sanitized properly. Failure to properly wash and sanitize glassware and dishes used by residents presents the potential for pathogen exposure and negative health outcomes.

Inspectors wroteBased on observations, staff interviews, medical record review, and facility policy review, the facility failed to maintain a clean and sanitary homelike environment for four (Residents #50, #1, #3, and #87) of seven residents receiving enteral nutrition. Sanitary includes, but is not limited to, preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored. It is the responsibility of all facility staff to create a homelike environment and promptly address any cleaning needs.

Inspectors wroteBased on observations, staff and resident interviews, medical record review, and facility policy review, the facility failed to provide services which met professional standards of quality, specifically leaving medications unattended at the resident's bedside, for four (Residents #12, #33, #105, and #50) of six residents observed during medication administration, from a total of 32 residents sampled. Professional standards of quality means that care and services are provided according to accepted standards of clinical practice.

Inspectors wroteBased on observations, resident and staff interviews, record review, and a review of facility training for all employees to include agency, the facility failed to honor the residents' right to be treated with dignity and respect, and failed to protect and value residents' private space by not knocking and asking for permission before entering the room for one (Resident #93) of two residents reviewed for dignity, from a total sample of 32 residents.

Inspectors wroteBased on observations, staff and resident interviews, medical record review, and facility policy review, the facility failed to provide reasonable accommodation of resident needs for one (Resident #8) in a sample of 32 residents. The facility failed to ensure that the resident had their call light within reach and was able to use it if desired.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure residents' personal privacy during medical treatment for one (Resident #50) of six residents observed during medication administration. Resident #50 was not provided privacy during medication administration via her gastrostomy tube (feeding tube). Each resident has the right to privacy and confidentiality for all aspects of care and services. A nursing home resident has the right to personal privacy of his or her own physical body.

Inspectors wroteBased on observations, interviews, record review, and review of facility training, the facility failed to ensure that a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for one (Resident #107) of three residents reviewed for ADLs, from a total sample of 32 residents.

Inspectors wroteBased on observations, staff and resident interviews, medical record review, and facility policy review, the facility failed to ensure disposition of medications for two (Resident #12 and Resident #105) six residents observed during administration of medications, from a total of 32 residents sampled. Method of disposition (including controlled medications) should prevent diversion and/or accidental exposure and is consistent with applicable state and federal requirements, local ordinances, and standards of practice.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive, person-centered care plan, by failing to 1) Ensure an Agency nurse appropriately assessed a resident's change in condition, including agitation, restlessness, and numerous attempts to jump out of bed for one (Resident #191) resident with a history of falls, behaviors, and suicidal ideation, out of four residents reviewed. The facility failed to ensure the Agency nurse recognized and addressed an emergent situation for a fall-risk resident, which contributed to her death. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to ensure resident safety, by failing to ensure the nursing staff recognized and managed a resident's change in condition, including agitation, restlessness, and numerous attempts to jump out of bed for one (Resident #191) resident with a history of falls, behaviors and suicidal ideation, out of four residents reviewed, from a total of 37 residents in the sample. The facility's failure to ensure nursing staff maintained appropriate skills sets and competencies contributed to Resident #191's death. The facility's employees and service providers failed to provide services to Resident #191 that were necessary to avoid physical harm. During the 3:00 p.m. to 11:00 p.m. [...]

Inspectors wroteBased on observations and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, by failing to maintain the kitchen in a safe and sanitary manner for the 90 residents in the facility.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure that a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for one (Resident #7) of two sampled residents, reviewed for ADLs, out of a total sample of 37 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents with a history of trauma and/or post-traumatic stress disorder, received appropriate treatment and services to correct the assessed problem or to attain their highest practicable mental and psychosocial well-being, by failing to ensure that seven (7) active Agency nursing staff received education on the identification of a change in condition with proper interventions and documentation per the facility's plan of correction. As a result of the recertification and complaint survey completed on 11/19/2021, the facility was cited at F742 (Treatment/Services for Mental/Psychosocial Concerns) at an Immediate Jeopardy (IJ) level. The IJ was removed at the time of the survey exit on 11/19/2021, however the facility remained out of compliance at a scope and severity of D. [...]

Inspectors wroteBased on interviews, record review and facility policies and procedures, the facility failed to maintain complete and accurate medical records in accordance with professional standards for one (Resident #23, who was receiving controlled medication for insomnia) of six residents sampled for unnecessary medication use were complete and accurate, from a total sample of 38 residents.