Palm Garden of Winter Haven

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure Preadmission Screening and Resident Review (PASRR) assessments were updated to include current diagnoses, for six residents (#74, #10, #69, #43, #65, and #5) out of 45 sampled residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to implement an effective infection control program related to ensuring staff were educated on transmission-based precautions (TBP) and the personal protective equipment (PPE) to be worn when entering isolation precaution rooms, and failed to ensure signage was posted related to the type of TBP for two residents (#44 and #83) out of two residents sampled for isolation precautions.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a dignified dining experience for one resident (# 66) out of eight residents sampled.

Inspectors wroteBased on interviews and record review, the facility failed to report an allegation of abuse within the required timeframe for one resident (#81) out of three residents sampled. Findings Include: An interview was conducted on 06/20/2024 at 1:00 p.m., with Staff L, Risk Manager (RM), and the Nursing Home Administrator (NHA). Staff L, reported Staff M, Registered Nurse (RN) Unit Manager, notified her on 6/12/ 2023 at 11:30 p.m. that Resident #81's family member had called around 10:30 p.m., and reported Resident #81 informed her (the family member) the assigned Certified Nursing Assistant, (CNA) was yelling and throwing things around in his room. The family member reported the CNA jumped on Resident #81's back and stomped on him. Staff L stated she was not able to hear everything Staff M, RN was saying to her over the phone due to poor phone reception. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to accurately assess and document the skin condition for one resident (#69) out of three residents sampled for skin conditions.

Inspectors wroteBased on record review and interview, the facility failed to ensure one resident (#7) out of the one sampled resident was appropriately assessed related to Post Traumatic Stress Disorder (PTSD).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the medication error rate was less that 5.00%. Twenty-six medication administration opportunities were observed and three errors were identified for two residents (#69 and #98) out of six residents observed. These errors constituted a 11.54% medication error rate.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure food was labeled and expired items were discarded in one nourishment room (100-hall) of two nourishment rooms.

Inspectors wroteBased on observation, record review and interviews, the facility failed to protect one (#1) resident from witnessed physical abuse by a staff member and failed to protect two residents (#2, #3) following allegations of abuse out of a total sample of four residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to implement the facility's Abuse, Neglect, Exploitation and Misappropriation policy and procedure for witnessed physical abuse of one resident (#1) and allegations of physical and verbal abuse of two residents (#2 and #3) of four sampled residents.

Inspectors wroteBased on record review and interviews, the facility failed to thoroughly investigate an allegation of physical abuse for one resident (#3) of four sampled residents.

Inspectors wroteBased on record review and interviews, the facility failed to develop a person-centered care plan to include a communication plan for a non-verbal resident for one resident (#3) of four sampled residents.

Inspectors wroteBased on observation, interview and record review the facility failed to provide housekeeping and maintenance services to maintain a sanitary and homelike environment related to not ensuring a mattress was in good repair for one resident (#9) of a sample of nine residents for two days (2/10/24 and 2/11/24) of a two day survey.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a medication administration error rate of less than 5%. A total of 36 administration opportunities were observed with 10 medication errors for three residents (#57, #443, and #49) of five residents observed for medication administration, resulting in a medication administration error rate of 38.46%.

Inspectors wroteBased on observations, interviews and medical record review, the facility failed to provide Activities of Daily Living (ADL) care for one dependent resident (#42) related to eating assistance out of a total sample of thirty-two residents.

Inspectors wroteBased on observations, interviews and policy review, the facility did not ensure one resident's (#392) food preferences were honored out of five sampled residents.

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 fifteen errors were identified for one resident (#52) of five residents observed. These errors constituted a 51.72% medication error rate.

Inspectors wroteBased on observations, record review, and interviews the facility failed to ensure one resident (#51) of 28 sampled residents was accurately assessed for the use of adaptive/bed rails as evidence by the presence of bilateral raised adaptive rails and the inaccurate screening for the rails during quarterly reviews for their use.

Inspectors wroteBased on observation, record review, and interviews the facility failed to review and revise a comprehensive, person-centered care plan by not including an intervention of adaptive/bed rails for one resident (#51) of 28 sampled residents.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that a physician order was written accurately for one resident (#23) out of five sampled residents for unnecessary medications.

Inspectors wroteBased on observations, record review, and interview the facility failed to accurately monitor the use of psychotropic medications for one resident (#79) out of five residents sampled for unnecessary medications.

Inspectors wroteBased on observations, record review, and interviews the facility failed to ensure one resident (#52) out of five residents observed during the mandatory task of Medication Administration received medication within the parameters ordered by the physician.

Inspectors wroteBased on record review and interviews, the facility failed to ensure documentation was accurate on the November and December 2020 Medication Administration Records (MAR) for two residents (Resident #23 and #4) out of 28 sampled residents.

Inspectors wroteBased on record review, staff interview and review of the policy and procedure, it was determined that the faciltiy did not ensure an effective Quality Assurance and Performance Improvement (QAPI) plan was implemented to monitor corrective action to ensure that adaptive rail assessments were accurate for three residents (#3, #5, #6) of four residents reviewed.