Palm Garden of Largo

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the safety of one resident (#2) out of three residents sampled. This failure resulted in a fall with major injury for Resident #2 when the individual care plan for transfer was not followed during a shower.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure proper infection control practices were utilized related to contact precautions on two resident units (100 and 200) out of three resident units in the facility.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to protect the resident's right to be free from neglect related to: 1) providing timely care and services to prevent physical/emotional discomfort for toileting assistance for one resident (#4) out of five residents sampled, and 2) protecting residents from unsympathetic/negative attitudes from staff for three residents (#6, #7, and #5) out of three residents sampled. These failures resulted in emotional/psychological distress and a fear of retaliation among residents.

Inspectors wroteBased on interview and record review, the facility failed to follow the comprehensive person-centered care plan for three (#2, #4, #5) of three sampled residents related to bed mobility and transfers.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure three (#320, #62, #321) of four residents reviewed for falls out of a total sample of 53 residents received accurate evaluations of fall risks to ensure adequate supervision, assistance devices, and individualized interventions were implemented to prevent accidents with injuries.

Inspectors wroteBased on record review and staff interviews, the facility failed to complete the Preadmission Screening and Resident Reviews (PASARRs) for residents with a mental disorder and individuals with intellectual disability following qualifying mental health diagnosis for four of four residents sampled for PASARRs (Residents #16, #20, #74 and #71).

Inspectors wroteBased on interviews and record review, the facility failed to ensure grievances were addressed in a timely manner for resident council members with potential to affect a census of 135.

Inspectors wroteBased on observations, interviews and medical record review, the facility failed to implement care plan interventions for four of fifty-three sampled residents (#106, #39, #109, #94), as evidenced by:1.) Staff not providing Resident #106 with a call light within his reach, while in bed and during two days observed (2/26/2024, 2/27/2024); 2.) Staff not performing and/or documenting monitoring of psychotropic medication use for Resident #106; 3.) Staff not coordinating dental services as needed for Resident #39; and 4). Failure to provide rehabilitation and restorative services for residents #109, and #94.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to revise and individualize a care plan to reflect a resident's condition for three residents (#320, 321, and 62) out of four sampled residents.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure the medication error rate was less than 5.00%. Thirty medication administration opportunities were observed, and five errors were identified for four (#17) out of five residents observed. These errors constituted a 16.67% medication error rate.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure medications were stored appropriately in six resident rooms (202, 207, 223, 304, 317 and 325), medications were stored in locked cart while unattended in one (A-wing #2) out of six carts, one insulin vial for one (#37) out of two residents sampled for insulin administration was not expired, medications with a shortened life once open were labeled with an open date on two (A-Wing#1 and Rehab #2) of three sampled medication carts, one (A-wing) of three medication refrigerators were locked and inaccessible to unauthorized personnel, and one (Rehab) out of three refrigerated controlled substance boxes were locked.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to initiate an effective Infection Control program related to the posting of precautions required for one (room [ROOM NUMBER]) of one rooms observed with a Personal Protective Equipment (PPE) caddy hanging from doorway, ensure direct care staff (Staff B, J, BB and DD) kept fingernails at an appropriate length and within policy parameters, ensure facility staff were knowledgeable on the types of PPE required to enter two resident rooms (#104 and #327) with posted precaution signage, and PPE caddies were stocked with required PPE for one (#104) of three residents on precautions.

Inspectors wroteBased on observations, staff interviews and medical record review, the facility failed to ensure one of fifty-three sampled residents (#76) was provided and maintained with privacy/dignity during two of four days observed (2/26/2024, and 2/27/2024).

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to protect a resident's right to be free from abuse and neglect, failed to ensure a resident who required one-person assistance with ADLs (activities of daily living), was provided timely care and assistance with toileting, and neglected to ensure a comfortable environment for one out of two residents reviewed (Resident #94.)

Inspectors wroteBased on staff interviews, record review and facility policy review, the facility failed to ensure allegations of abuse and neglect were investigated for one (#94) of two residents reviewed.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure skin conditions were identified and treated for three (#57, #274, and #21) out of nine residents reviewed for skin conditions and failed to identify and respond to one (#325) out of one residents sampled for change in condition in a timely manner that resulted in a hospitalization.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to respond to the consultant pharmacist's recommendations in a timely and accurate manner and for one (#3) out of 5 residents sampled for the administration of unnecessary medications.

Inspectors wroteBased on observations, interviews, and medical record review, the facility failed to ensure one of six sampled residents (#106) for use of psychotropic medication use, was monitored and documented for signs/symptoms/side effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (#39) of two residents sampled for dental care received dental services to meet her needs as requested.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to collaborate care with an external provider for one (#74) out of one resident sampled for Hospice services, as evidenced by not ensuring staff collaborated care with the provider, the medical record contained provider assessments, and staff had knowledge of the services provided by the Hospice staff.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of fifty-three sampled residents (#106) was provided a call light button and placed within his reach, while in bed and during two of four days observed (2/26/2024, and 2/27/2024).

Inspectors wrote3. Resident observed on 12/8/2021 at 12:18 p.m. with linear and circular markings along the left shoulder and Right lower leg. Resident #64 was observed scratching at her shoulder. Review of weekly skin checks dated 12/9/2021 revealed the resident had impaired skin. Review of the Situation, Background, Appearance, Review and notify (SBAR) form dated 12/9/21 detailed the resident with skin or wound ulcer. Primary care clinician notified on 12/9/21 at 11:40 a.m. and ordered lac hydrin lotion for dry skin. Review of the weekly skin assessment dated [DATE] at 5:13 p.m. revealed the resident with intact skin. Review of the weekly skin assessment dated [DATE] at 5:13 p.m. revealed the resident with intact skin. Review of the weekly skin assessment dated [DATE] at 8:13 p.m. revealed the resident with intact skin. Review of the weekly skin assessment dated [DATE] at 8:13 p.m. [...]

Inspectors wroteBased on observations, record review, interviews, and the facility Plan of Correction review, the facility failed to ensure it had a functioning Quality Assurance Committee. The facility had deficient practices identified during the Recertification and Complaint survey for complaint numbers 2021003271, 2020019788, and 2020011362, conducted on [DATE] to [DATE] and was cited F684. The facility developed a Plan of Correction with a completion date of [DATE]. On [DATE], the facility was recited F684 for failure to ensure Best Practice for Peripherally Inserted Central Catheters (PICC) was utilized for three (#5, #9, #10) out of three sampled residents on intravenous therapy, as evidenced by omitted monitoring, medication, intermediate flushes, and dressing changes. The facility had not comprehensively implemented the plan of correction for the identified deficiency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure reasonable accommodation for one (#34) out thirty-six sampled residents as evidenced by not keeping fluids within reach due to visual impairment.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to develop comprehensive care plans related to the monitoring and placement of an elopement bracelet alarm on one (Resident # 424) of five residents sampled for accidents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure prescribed biological medications were secured for one Resident #29 on three (12/08/21, 12/09/21 and 12/10/21) of four days observed. Findings Included: During an interview and observation with Resident #29 on 12/8/21 at 12:48 p.m. three tubes of medication were observed in a clear plastic bag in the resident's room. The medications were Clotrimazole-Betamethasone Cream, Ammonium Lactate Cream 12%, and triple antibiotic ointment, and were labelled with the resident's last name. Photographic evidence was obtained. On 12/09/21 at 10:32 a.m. Resident #29 was observed sitting in a recliner talking with the nurse. The bag containing the three biological medications was observed on the resident's bedside table. An observation on 12/10/21 at 8:00 a.m. [...]

Inspectors wroteBased on observations, record review, and interviews the facility: 1. failed to provide a permanently affixed compartment for storage of controlled drugs in three medication storage room refrigerators (A-Wing, C-Wing and Rehab Unit) of 3 refrigerators, and 2. failed to ensure that an opened insulin pen was labeled with the date opened in one medication storage room refrigerator (Rehab Unit) of three medication storage room refrigerators.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a care plan intervention related to fall prevention as written and determined by the facility's Interdisciplinary Team for one resident (#59) of four residents that required floor mats.