Palm Garden of Pinellas

Inspectors wroteBased on interviews and record review, the facility failed to provide care and treatment in accordance with professional standards and failed to send the resident to higher level of care, upon request for one (Resident #2) of two residents sampled. Resident #2 experienced a change of condition on [DATE] with a delay treatment according to professional standard of practice. Cross-reference F580.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the residents' family and physician was notified of a significant change in condition for one (Resident #2) of two residents sampled. Cross-reference F684.

Inspectors wroteBased on observations and interviews, the facility did not ensure food safety standards were followed, in the kitchen and two of two nourishment rooms, as evidenced by improper infection control practices including hand hygiene, ice buildup in the walk-in freezer, the dish machine and dumpster areas not maintained in a clean sanitary condition, and resident food items were not labeled/dated.

Inspectors wrote4. On 05/15/2025 at 12:07 PM Staff U, Laundry Aide was observed placing clean laundry under his chin during laundry folding. Staff U let a sheet touch the floor while he was folding. Staff U stated he should not place the laundry under his chin. He stated he was trying to remember not to do that. He stated he did that at home when he folded his personal laundry. During an interview on 05/15/2025 at 1:21 PM the Infection Control Preventionist (ICP) stated hand sanitizing was to be used between each resident contact. He stated hand sanitizing was to be performed between each resident they pass a tray to. ICP stated they encourage the residents to hand sanitize also. The ICP stated the staff was to hand sanitize between each resident. The ICP stated the staff was to have their own hand sanitizer or use the machines on the wall. [...]

Inspectors wroteBased on interview and record review, the facility failed to file and act upon grievances voiced during resident council meetings for 6 meetings on (4/30/25, 3/26/25, 2/26/25, 1/29/25, 12/31/24 and 11/29/24) of six Resident Council Meetings Minutes reviewed, with a potential to affect a census of 107.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents reviewed for Beneficiary Protection Notification received the required Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) form prior to the end of Medicare part A services for two (#64 and #159) of three residents reviewed. Findings Included: Review of record revealed Resident #64 had Medicare A days remaining in the benefit period. The facility informed Resident #64 of Medicare part A services would be terminated on 4/24/25. Resident #64 was choosing to remain in the facility. The facility did not complete form SNF-ABN as required. Review of record revealed Resident #159 had Medicare part A days remaining in the benefit period. The facility informed Resident #159 Medicare part A services would be terminated on 5/6/25. Resident #159 was choosing to remain in the facility. [...]

Inspectors wrote2. During interviews on 5/12/25 at 1:46 PM and 05/13/25 at 09:46 AM Resident #92 stated speaking with multiple staff members, including the dietary manager regarding his preferences not being followed. Resident #92 stated nothing changes and no follow up occurs, they don't listen. Review of the clinical record for Resident #92 shows resident was admitted on [DATE]. The resident's most recent quarterly Minimum Data Set, dated [DATE] shows resident is cognitively intact. A review of the Grievance Logs from February to May 2025, revealed a grievance for Resident #92 related to dietary/culinary preferences dated 2/13/25. The grievance reveals Resident #92 unhappy with dietary/culinary preferences, receiving cold food all meals, burnt toast, what he receives doesn't match what he requests. Has asked not to receive these items several times. The response on the form revealed: [...]

Inspectors wrote3. On 05/12/25 at 09:53 AM Resident #33 was observed lying in bed in a facility gown, just above resident elbow on the right upper extremity red circular spots were noted. Resident stated having a rash that was extremely itchy. Resident continued this is much better, the physician visited and prescribed a cream the facility has been applying. Review of the admission Record showed Resident #33 was admitted to the facility on [DATE] with diagnoses that included but not limited to Generalized Anxiety Disorder, and Major Depressive Disorder. Review of Resident #33's Minimum Data Set (MDS) most recent quarterly assessment dated [DATE] revealed resident is cognitively intact, with a Brief Interview for Mental Status (BIMS) of 15/15. Review of Resident #33's Dermatology Provider Note dated 04/24/2025 revealed new resident to be seen per administration to rule out contagion. [...]

Inspectors wroteBased on observation interview and record review the facility failed to provide an environment free from falls and failed to ensure documentation of assessments and neurological checks post fall, for three (#93 #11 and #10) of three residents sampled.

Inspectors wrote2. During an interview and observation on 05/12/25 at 09:53 AM, Resident #33 was teary eyed and emotionally upset as she discussed her prior nursing home experience. Resident #33 stated she was abused and treated badly at the previous nursing home. Resident #33 stated since being admitted to the facility no one had discussed the diagnosis of PTSD or any triggers that would cause her re-traumatization. Resident #33 stated being seen by psychology/psychiatrist at the facility. Review of the admission Record showed Resident #33 was admitted to the facility on [DATE] with diagnoses that included but not limited to Generalized Anxiety Disorder, and Major Depressive Disorder, and other comorbidities. [...]

Inspectors wrote2. On 05/14/2025 at 8:34 a.m. Resident #38 was observed dozing in bed. Her breakfast was on her overbed table. The head of the bed was elevated. Resident #38 was admitted on [DATE]Review of the admission Record showed diagnoses included but not limited to after care following a total knee replacement, sepsis due to Methicillin Resistant Staphylococcus Aureus (MRSA), infection and inflammatory reaction due to internal left knee prosthesis, intraspinal abscess and granuloma, enterocolitis due to clostridium difficile, difficulty in walking, heart failure, Rheumatoid arthritis. Review of the Minimum Data Set, dated [DATE] showed Section C, Cognitive Patterns, Brief Interview for Mental Status of 12, cognitively intact. Review of physician orders showed Cephalexin (Keflex) 500 mg twice day for MRSA left knee, suppressive therapy for life, no stop date as of 03/03/2025. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the Minimum Data Set (MDS) was accurate related to discharge reason for one (#106) of 50 sampled residents.

Inspectors wroteBased on record review and staff interview, the facility failed to complete and or update the Pre-admission Screening and Resident Reviews (PASARRs) for residents with a mental disorder and individuals with intellectual disability following qualifying mental health diagnoses for two (#12 and #6) of six residents reviewed for PASARRs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure personal hygiene needs were provided to one (#76) of two dependent residents sampled for Activities of Daily Living (ADL).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure devices for contracture prevention were provided as ordered for two (#76 and #82) of two residents sampled.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure medications were administered prior to dialysis appointments for one (#93) of one sampled resident.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure the medication error rate was less than 5%. Thirty-three medication opportunities were observed, and two errors were identified for Resident #1 resulting in an error rate of 6.06%

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to protect the resident's right to be free from neglect by not ensuring one resident (#1) of six residents at risk for elopement with a known history of exit seeking behaviors, and an expressed desire to leave the facility, was provided supervision and services to prevent elopement. Resident #1, on 3/25/2024 at approximately 4:15 p.m., exited the facility without being seen by staff members. Resident #1 exited through an ambulance side (C-Wing) entrance door of the facility, which was equipped with an electromagnetic locking device (a magnetic lock that was unlocked when de-energized and required power to remain locked). Resident #1 was able open the door by punching the security code into the keypad beside the door. She walked out of the door and around the outside of the facility for approximately 13 minutes. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure one resident (#1) of six residents at risk for elopement, was provided with supervision and services related to the resident's cognitive deficits, lack of safety awareness, and confusion before admission to the facility. The facility staff failed to ensure the supervision and safety of Resident #1 on 3/25/2024 at approximately 4:15 p.m. Resident #1 exited the facility through an ambulance side (C Wing) entrance door that was equipped with an electromagnetic locking device (a magnetic lock that unlocked when de-energized and required power to remain locked). Resident #1 was able open the door by punching the security code into the keypad beside the door. [...]

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure that two (#24 and #66) out of two sampled residents had a Preadmission Screening and Resident Review (PASRR) that reflected an accurate screen decision-making for mental illness or suspected mental illness.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure identification of need, and development and implementation of an individualized one to one activities program to support the physical, mental, and psychosocial well-being for two residents diagnosed with dementia (Resident #108 and Resident #66) out of two sampled residents.

Inspectors wroteBased on observation, interview and medical record review, the facility failed to ensure an active comprehensive assessment for one Resident (#24) out of one, total of thirty seven, sampled for accurate psychiatric and mood disorder diagnosis.

Inspectors wroteBased on observation, interview and medical record review, the facility failed to ensure one (#90) out of two residents sampled for communication and sensory were provided care and treatment in timely manner for a hearing deficit.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure the Consulting Pharmacist recommendations were addressed in a timely manner for one (#4) out of five residents sampled for the task of unnecessary medications.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow infection prevention and control procedures related to antibiotic stewardship for two (#12 and #28) of three resident reviewed for prophylactic antibiotic use.

Inspectors wroteBased on observations, staff & resident interview and record review, the facility failed to ensure two of thirty-six sampled residents' (#57, #24)'s care plan interventions were implemented related to: 1. Resident #57's left hand splint not applied consistent with the Activities of Daily Living (ADL) care plan, during two of four days observed (6/28/2021, 6/29/2021); 2. Staff did not ensure a call light cord was placed within #24's reach during two of four days observed (6/28/2021, 6/29/2021).

Inspectors wroteBased on observations, record review, and interviews the facility failed to discontinue an indwelling catheter as prescribed by the physician and in a timely manner for a resident who did not have a diagnosis which supported the use of a catheter for one (#85) out of four residents sampled for urinary catheters.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure Pharmacy Recommendations were addressed by the provider for one (#73) of five residents sampled for the mandatory task of Unnecessary Medications.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that the medication error rate was less than 5.00%. Twenty-nine medication administration opportunities were observed, and two errors were identified for two (#97 and #204) of seven residents observed. These errors constituted a 6.8% medication error rate.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure drugs and biologicals were stored & labeled with currently accepted professional principles regarding 1. Narcotic containers not permanently affixed in 2 (A Wing & C Wing) of 2 refrigerators 2. Insulin pens and eye drops not labeled with Expiration dates or expired in 2 of 3 medication carts (A-1 and C-5) & and 3. Narcotic count not reconciled in one (A-1) of 2 medication refrigerators.

Inspectors wroteBased on observation, record review, interviews, policy review, and review of the facility's Plan of Correction, the facility failed to ensure that it had a functioning Quality Assurance Committee. The facility was actively involved in the effective creation, implementation and monitoring of the Plan of Correction for deficient practice identified during a recertification survey and complaint investigation conducted on 6/28/2021 through 7/1/2021; F759 and F761 were cited. On 09/07/2021 deficient practice was identified related to F759 and F761. The facility had developed a Plan of Correction with a completion date 07/31/2021.