Palm Garden of Sun City

Inspectors wroteBased on interviews and record review, the facility failed to investigate and work to resolve complaints/grievances related to allegations of poor staff treatment for one resident (#1) out of three residents sampled.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident was free from a fall during incontinent care for 1 of 3 resident sampled (#3) who required 2-person assistance for bed mobility. Findings Include: Review of an admission record dated [DATE] showed Resident # 3 was admitted to the facility originally on [DATE] and readmitted on [DATE] with diagnoses to include but not limited to other abnormalities of gait and mobility, other lack of coordination, acquired absence of right and left leg above knee. Review of a change in condition dated [DATE] showed Resident # 3 had a change in condition due to a fall. Resident has a small skin tear to forehead. Transferred to bed facility protocol initiated. On [DATE] at 10:44 AM. an interview was conducted with Staff A, License Practical Nurse, LPN. Staff A stated she has worked at the facility for 20 years. [...]

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to protect the resident's right to be free from neglect related to not ensuring a safe transfer from a wheelchair to a bed for one resident (Resident #2) of three sampled residents requiring staff assistance with a mechanical lift for transfers. This failure created a situation where the resident fell from the mechanical lift to the floor, causing injuries resulting in transfer to a higher level of care for treatment.

Inspectors wroteBased on observations, interviews, and record review the facility failed to protect the right to be free from neglect related to pain management, contracture management, activities of daily living (ADL) care, and seating systems for one resident (#91) out of 38 total sampled residents.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure pain was managed for one resident (#91) out of three residents reviewed for pain out of a total sample of 38 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure dietary staff were wearing hair nets, temperature logs were completed, and food items were labeled, dated, and stored according to professional standards for food safety services in one of one kitchen, one of one dining room, one of two nourishment rooms, and one of one activity room.

Inspectors wrote2. Review of the admission Record showed Resident #15 was admitted on [DATE] and re-admitted on [DATE] with diagnoses including post-traumatic stress disorder, bipolar disorder, unspecified dementia, major depressive disorder, and unspecified mood (affective) disorder. Review of Resident #15's PASRR Level I Screen, dated 6/5/24, indicated anxiety disorder, bipolar disorder, and depressive disorder. Section II, #7 indicated No to the question asking if the resident had dementia. 3. Review of the admission Record showed Resident #59 was admitted on [DATE] and re-admitted on [DATE] with diagnoses including anxiety disorder, major depressive disorder, and adjustment disorder with mixed anxiety and depressed mood. Review of Resident #59's PASRR Level I Screen, dated 6/15/22, did not indicate any mental illness or suspected mental illness. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not ensure medications were stored properly on two out of three units and in three out of three medication carts.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure proper infection control practices in two out of three units related to incorrect transmission-based precaution signs, lack of hand hygiene during tray pass, improper storage of respiratory masks, and improper personal protective equipment (PPE) usage.

Inspectors wroteBased on interview and record review the facility failed to ensure dignity was maintained for one (Resident #257) out of three residents reviewed for dignity out of a total resident sample of 38.

Inspectors wroteBased on observation, record review, and interview the facility failed to develop a care plan for splint management and impaired vision for two residents (#9 and #59) out of 38 sampled residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one resident (#9) out of four residents reviewed for orthotic devices received physician ordered splint management for prevention and worsening of a contracture.

Inspectors wroteBased on observations, record review, and interview, the facility failed to provide a well-balanced special diet for one of two residents (Resident # 25) reviewed for special diets.

Inspectors wrote2. Review of the admission Record showed Resident #91 was admitted on [DATE] with diagnoses to include nontraumatic intracerebral hemorrhage, moyamoya disease, adult failure to thrive, dementia, moderate, contracture of muscle right and left lower leg, and type II diabetes mellitus. Review of Resident #91's Minimum Data Set (MDS) assessment for a significant change, dated 7/15/24, showed upper and lower extremity impairment on both sides, use of a manual wheelchair, and dependent on a helper for eating, hygiene, bathing, and dressing. Review of Task documentation by the Certified Nursing Assistants (CNAs) for Resident #91 showed the following: [...]

Inspectors wroteBased on observation, interview and policy review, the facility failed to maintain clean and sanitary equipment in the kitchen area related to the dish machine, ice machines, convection ovens, walls and floors, and failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety related to labeling and dating of food, recording temperatures for refrigeration and for the dish machine and failed to utilize sanitizing buckets in the kitchen for three days (8/22/22, 8/23/22 and 8/24/22) of a four day survey.

Inspectors wroteBased on observation, interview and record review the facility failed to implement an effective infection control program related to transmission-based precautions by not ensuring five staff members (L, H, A, C, D) adhered to the appropriate use of Personal Protective Equipment (PPE) for four residents (#31, #249, #148 and #76) with the potential to affect a census of 113 residents.

Inspectors wroteBased on observation, interview, record review and review of the facility's policy and procedure the facility failed to file a grievance on behalf of two residents (#63 and #250) out of 38 sampled residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure care plan interventions for the use of a mechanical lift were implemented for one (Resident #27) of two residents sampled for positioning and mobility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that one (Resident #80) of three sampled residents received treatment and care in accordance with professional standards of practice related to wound treatments. Findings Included: Observation of lunch service on 4/27/21 at 12:15 p.m., revealed Resident #80 with a right elbow dressing dated 4/22/21. During an interview with the resident, she stated during care the CNA (Certified Nursing Assistant) pulled her up in bed and scraped her elbow. During an interview with Staff I, Licensed Practical Nurse (LPN) on 4/27/21 at 12:30 p.m., she confirmed the date of the dressing was 4/22/21 and confirmed she could not locate an order for the dressing or wound care. She confirmed that on 4/18/21, the resident received a skin tear while a CNA was pulling the resident up in bed by herself. [...]

Inspectors wroteBased on record review and interview, the facility failed to conduct a root cause analysis of falls to ensure appropriate and effective interventions were in place to prevent additional falls and injuries for one (Resident #29) of three sampled residents.