Palms at Sebring Nursing and Rehabilitation the

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide antiretroviral medication for an immunocompromised resident for one resident (# 1) out of three residents sampled.

Inspectors wroteBased on interviews and record review, the facility did not ensure grievances were documented and/or resolved for the Resident Council for five months in 2025 (June, July, August, September and October 2025) out of five months reviewed.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure three residents (#41, #167, and #168) out of three residents reviewed for beneficiary notifications were provided with the correct notification prior to changes of skilled services and related changes.

Inspectors wroteDuring an interview on 2/25/25 at 5:48 p.m., the Director of Nursing (DON) stated the expectation is the facility mark the MDS assessments accurately. 3. Review of admission Records showed Resident #56 was admitted on [DATE] with diagnoses including morbid obesity and diabetes mellitus with diabetic neuropathy. Review of Resident 56's care plan showed a focus area of ADL self-care performance deficit with interventions including TRANSFER: The resident requires partial/moderate assistance by staff to move between surfaces, dated 8/13/24. Review of Resident #56's 2/7/25 Quarterly MDS, Section GG, Functional Abilities, showed for chair/bed-to-chair transfer the resident is partial/moderate assistance. An interview was conducted on 2/24/25 at 2:52 p.m. with the Director of Rehab (DOR). [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure the Level I Preadmission Screening and Resident Review (PASRR) were accurately completed for nine residents (#44, #55, #91, #94, #33, #39, #56, #6, and #5) out of 22 sampled residents.

Inspectors wroteBased on observations, interviews, and record review, the facility did not ensure the development and implementation of the comprehensive care plan for five residents (#104, #4, #56, #39, and #6) out of twenty-two residents sampled.

Inspectors wroteBased on interviews and record reviews the facility did not ensure care plans were revised for five residents (#13, #10, #6, #65, and #89) out of twenty-two sampled residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide care treatment and care in accordance with professional standards of practice related to 1.) did not ensure three residents (#13, #10, and #39) were assisted with eating, 2.) did not ensure two residents (#4 and #56) were assessed for transfers and provided wheelchairs, 3.) did not ensure notification of change in condition was completed appropriately for one resident (#29), 4.) did not ensure one resident (#309) was assessed appropriately for pain, and 5.) did not ensure wound care was provided for two residents (#71 and #89) out of twenty-two sampled residents.

Inspectors wroteBased on observations, interviews, and record review, the facility did not ensure food preferences were honored for four residents (#309, #28, #39, and #71) out of twenty-two residents sampled.

Inspectors wroteBased on observations and interviews, the facility did not ensure dignity was maintained for residents in one out of two dining rooms related to residents at a single table not being served meals at the same time.

Inspectors wroteBased on interviews and record review, the facility failed to honor resident rights to formulate advance directives for two residents (#259 and #94) of 22 residents sampled for advance directives.

Inspectors wroteBased on observation and interview, the facility did not ensure privacy of residents' personal health information on one unit (East) out of two units in the facility.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the prevention of the development of pressure wounds for one resident (#28) out of eight residents sampled.

Inspectors wroteBased on observations, interviews, and record reviews, the facility did not ensure the environment was free of possible accident hazards related to smoking materials for one resident (#104) of one resident sampled for smoking and related to razors and scissors in two resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) of thirty-one resident rooms observed.

Inspectors wroteBased on observations, interviews, and record review, the facility did not ensure post-dialysis communication was implemented and documented in the medical records for one resident (#33) of one resident sampled for dialysis.

Inspectors wroteBased on interview and record review, the facility did not ensure pharmacy recommendations were completed for two residents (#57 and #5) out of five reviewed for unnecessary medications.

Inspectors wroteBased on observations and interviews, the facility did not ensure medications were stored properly on two out of two units in the facility related to unlocked medication carts, unsecured medication, and medication in resident rooms.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to implement protocols from the facility's antibiotic stewardship program for one resident (#3) out of three residents reviewed for antibiotic use.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the protection of a resident's right to remain at the facility by issuing an inaccurate reason on a thirty-day Nursing Home Transfer and Discharge Notice for one resident (#4) out of one resident reviewed for admission, transfer, and discharge.

Inspectors wroteBased on observation, staff interview and policy review the facility failed to store food in accordance with professional standards for food service safety as evidenced by failure to discard food items that were expired, unlabeled and undated food items in the kitchen and one of two medication storage rooms, and one dietary staff member not wearing a hair net in the kitchen area. Findings Included: An observation, during the initial kitchen tour on 01/09/23 at 9:25 AM, revealed two (2) low-fat 1% gallons of milk that had an expiration of 12/28/2022. An immediate interview on 01/09/23 at 9:25 AM, Dietary Staff C confirmed the milk was expired and stated, hopefully no one used it. An observation, on 01/09/23 at 9:30 AM, revealed a handful of yellow colored hard tubular food product that was wrapped up with plastic wrap that was not labeled or dated. An immediate interview on 01/09/23 at 9: [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure the binding arbitration agreement explicitly informed the resident or their representative of the right to not sign it for three residents (#12, #41, and #24) of three residents sampled.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to provide Pneumococcal vaccinations for three (Residents #4, #12, and #33) of five residents sampled for Pneumococcal vaccinations, failed to provide influenza vaccinations for three (Residents #12, 33, and 63) of five residents sampled for influenza vaccinations, and failed to provide COVID-19 vaccinations for two (Residents #33 and 63) out of five residents sampled for COVID-19 vaccinations.

Inspectors wroteBased on observation, record review, interview, and policy review the facility failed to provide care and services related to catheter care for one resident (#25) out of six residents with indwelling catheters.

Inspectors wroteBased on observations, interviews, record review, and policy reviews facility failed to ensure one resident (#25) out of thirty-one sampled residents received trauma-informed care in accordance with professional standards of practice and accounted for the resident's experiences and preferences in order to eliminate or mitigate triggers that may cause traumatization.

Inspectors wroteBased on interview and record review, the facility failed to develop a resident-centered plan of care related to Dementia Care for one (#21) of one resident reviewed for dementia care out of 21 facility residents with dementia related diagnosis or Alzheimers' disease.

Inspectors wroteBased on observations, staff interviews, and facility file review, the facility did not ensure a safe, clean, comfortable, and homelike environment during four of four days observed (4/20/2021, 4/21/2021, 4/22/2021, and 4/23/2021) as evidenced by: 1) one of one smoking area observed with cigarette butts on the ground and cigarette butts in a trash can that was not fire rated, 2) seating equipment in disrepair in one (first floor) of two dining rooms, and 3) Twelve (203, 204, 206, 210, 211, 213, 216, 219, 222, 227, 230, 231) of 62 resident rooms with soiled floors, cracked and chipped tiles, unbagged plungers, and walls in disrepair.

Inspectors wroteBased on observations, interviews, and review of clinical records and policies and procedures, the facility failed to develop a care plan for one (#30) of 32 sampled residents related to respiratory care and behaviors and failed to implement care plan interventions related to smoking for one (#59) of 32 sampled residents.

Inspectors wroteBased on record review, observation, interviews, and policy review the facility did not ensure systems and processes for treatment of a pressure ulcer were implemented related to timely treatment of infection, appropriate disinfection of treatment supplies, maintenance of dressings on a pressure ulcer, adequate cleansing of the pressure ulcer, and appropriate application of the ordered treatment in a manner to prevent the worsening of a pressure ulcer for one resident (#40) of two residents sampled for care and services for pressure ulcers.

Inspectors wroteBased on record review, interviews, and policy review the facility failed to ensure a root cause analysis and meaningful interventions were implemented to prevent accidents for one (#8) of three residents reviewed for falls.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to provide necessary respiratory care and services, related to proper storage of a nebulizer machine and continuous positive airway pressure (CPAP) treatments, consistent with professional standards of practice for one (Resident #30) of one resident investigated for respiratory care.

Inspectors wroteBased on observations and interviews the facility did not ensure appropriately stored refrigerated controlled substances in two of two medication refrigerators in two of two medication storage rooms on two of two nursing units (the first and second floors).

Inspectors wroteBased on observations, interviews, and record reviews the facility did not ensure two (#282, #17) of two sampled hospice residents had a record of the benefit of election for hospice and a hospice plan of care or indication of hospice personnel involved in hospice care and working in collaboration with the facility.