Palm Garden of Tampa

Inspectors wroteBased on observations, interviews, and record review the facility did not ensure medications were stored in accordance with current professional standards for 4 of 6 medication carts and 1 of 2 medication storage rooms.

Inspectors wroteBased on observations, interviews, and record review the facility did not ensure specialized call light was within reach for one (Resident #3) of four residents sampled for call lights.

Inspectors wroteBased on observations, interviews and record review, the facility failed to develop care plans with goals and interventions for two residents (#52 and #105) of 2 residents reviewed for care plans, related to: 1. Not developing care plan to reflect Resident #105 who had a diagnosis of Post Traumatic Stress Disorder (PTSD); 2. Facility and Resident #52 having a video camera facing from the hallway into the room and the need for two or more staff members to enter the resident's room for any reason to include care and services.

Inspectors wroteThe facility did not ensure one (Resident #11) was provided with adequate pain management out of three residents sampled for pain management. On 5/04/26 at 2:09 p.m., an interview was conducted with Resident #11. Resident #11 stated she had a Leave of Absence (LOA) from the facility the morning of 4/24/26 and returned to the facility on the morning of 4/26/26. On 4/24/26, Resident #11 stated she was provided one Oxycodone tablet when she left on LOA. She stated her nurse told her there was only one tablet remaining in her prescription. She stated she experienced pain while on LOA, and one tablet was not enough to address the pain. Resident #11 stated a family member provided her with Tylenol, but it was not enough for her pain. Resident #11 stated she was not offered an option to delay her LOA until her prescription was refilled. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one of two residents (#105) who were diagnosed with Post Traumatic Stress Disorder (PTSD), were assessed and monitored for specific trauma related behaviors and failed to ensure care staff were aware of resident #105 having PTSD, and having knowledge of what specific trauma based behaviors to look out for.

Inspectors wroteBased on interviews and record review, the facility did not ensure medication recommendations were reviewed for one (Resident #4) of five residents sampled for unnecessary medications.

Inspectors wroteBased on observations, interviews, and record review the facility did not provide therapy services needed for one (Resident #38) of one resident sampled for specialized rehabilitative services .

Inspectors wroteBased on interviews and record review the facility failed to allow one (Resident #2) to return after hospitalization of three residents reviewed for readmission.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an effective pest control program as evidenced by small gnat like flies observed in the kitchen at the hand washing station, inside the dry storage area, inside the freezer, the dish cleaning area, around a cart outside of the freezer, and flies were observed over the tray/cook line for two days (11/13/23 and 11/15/23) out of four days of survey.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to resolve grievances related to dietary concerns in a timely manner for two residents (#4 and #85) out of the two sampled residents for grievances.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to reassess the need for an appropriate use of bed rails for one resident (#80) of three residents sampled for bed rails.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure medications were stored in a safe manner in regards to 1) leaving one of two treatment carts unlocked while unattended (C-wing), 2) unopened eye drops requiring refrigeration stored in one (100-hall team #2) out of six medication carts, 3) one (C-wing team #3) out of six medication carts held medication tablets in a medication cup and a loose tablet, 4) three (C-wing, A-wing team #2, C-wing team #1) out of six medications carts left unlocked while unattended, 5) medications left on top of two unattended medication carts (100 team #2 and A-wing) out of 6 carts, 6) allowing a visitor unattended access to an unlocked medication cart (A-wing team #2 and C-wing team #1) out of six carts, and 7) allowed one resident (#85) to have a prescribed Albuterol inhaler at bedside.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide access to activities for one resident (#74) out of one resident sampled for activities.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to allow two residents (#64 and #62) out of 40 sampled residents to exercise their autonomy related to the individual preference of having a personal refrigerator in their room.

Inspectors wroteBased on observations, interviews and record review, the facility failed to inform the resident/resident representative of a change in status and change in medication for two residents (#99 and #314) of two residents sampled for change of status.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide treatment and care according to physician orders for non-pressure related skin conditions for two residents (#314 and #316) of two residents sampled for skin conditions.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the medication error rate was less than 5.00%. Thirty-seven medication administration opportunities were observed and nine errors were identified for two residents (#211 and #25) of four residents observed. These errors constituted a 24.32% medication error rate.

Inspectors wroteBased on observation, record review, and interviews the facility failed to ensure one resident (#30) was assessed for self-administration of a medication and that the medication was not stored at bedside out of five residents sampled for unnecessary medications.

Inspectors wroteBased on observation, interview with the resident, interview with facility staff, and review of facility documents, the facility failed to provide one resident with impaired vision, (Resident #56) with assistance at meals, leisure activities to meet his needs of a total sample of 21 residents reviewed for accommodation of needs.

Inspectors wroteBased on observation, resident and facility staff interviews, and review of facility documents, the facility failed to revise a care plan to meet the needs related to accommodating needs, specifically for impaired vision for one resident (#56) of 21 residents reviewed.

Inspectors wroteBased on observations, interview and record review the facility failed to ensure treatment and care was provided related to the appropriate application of a splint for one resident (#81) of 48 sampled residents.

Inspectors wroteBased on interviews, observation of the resident (#140) at meals, and review of the resident's medical record and facility documents, the facility failed to ensure one (#140) of one resident reviewed for dialysis services received care and services to meet her needs.

Inspectors wrote4. On 09/21/2021 beginning at 2:45 p.m., an observation began of the 100 wing for sufficient staff. Initially only two aides were observed, both in and near to the day room. One aide was providing one on one care to a male resident and the second was talking with that aide. No other aides were observed on the unit. At 2:49 p.m. while walking the halls to observe for the aides, at the end of the high numbered rooms, a resident called out for help. When the surveyors approached the resident she asked for help, that she was wet and needed to be changed. The surveyors asked her to put her call bell on and someone would come to assist. The surveyors walked up the hall, continuing to look for aides and finally when they reached the nursing station without observing any aides, they asked they nurses where their staff were. [...]

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure target behaviors, side effects, and outcomes were monitored and documented for two (#6 and #30) out of five residents sampled for 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%. Thirty-six medication administration opportunities were observed, and twenty-three errors were identified for three (#66, #90, and #58) of five observed residents. These errors constituted a 63.8% medication error rate.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure medications stored in three (A-Wing 3, C-Wing 1, and C-Wing 2) out of the six facility medication carts were stored appropriately as evidenced by narcotic medications not accounted for when administered and medications were not dated when opened when medications had a shortened shelf life.

Inspectors wroteBased on observation of dietary staff, interview with dietary staff, and review of dietary documents, the facility failed to ensure the kitchen equipment was maintained in a clean manner, items stored in the walk in refrigerator were dated and discarded when indicated by the date, the temperature and sanitation logs for the dish machine were accurately completed, and a floor drain was kept clean.