Federal inspectors found the facility failed to provide appropriate pressure ulcer care for Resident #3, who was readmitted to the nursing home earlier this year. Her admission assessment documented redness to her buttocks area — a clear warning sign that pressure ulcers could develop.
The resident required moderate assistance for turning right to left in bed and was completely dependent on staff for toileting, according to her quarterly assessment. Both conditions significantly increase pressure ulcer risk.
Yet physician orders for Resident #3 contained no instructions to prevent skin breakdown.
By late April, what started as redness had become open wounds. A skin assessment revealed an open wound to her sacrum and left buttocks. Three days later, staff called the resident's daughter to inform her about the deteriorating condition.
The daughter told staff she was unaware of any redness when her mother returned to the facility, according to a progress note dated April 25. Staff acknowledged they had not informed the family about the non-blanchable redness her mother had upon readmission.
The situation worsened rapidly. A wound care consultation on April 28 documented that Resident #3 had developed a stage 4 pressure ulcer to the sacrum and a stage 3 pressure ulcer to the left buttocks.
Stage 4 pressure ulcers represent the most severe category of bedsores, involving full-thickness tissue loss with exposed bone, tendon, or muscle. Stage 3 ulcers involve full-thickness skin loss with visible fat tissue.
The facility's care plan revealed no documented focus stating Resident #3 was at risk of developing pressure ulcers, despite the obvious warning signs present at admission.
When federal inspectors interviewed the Director of Nursing on December 29, she initially deflected questions about whether the resident had facility-acquired pressure ulcers. "I pulled some information regarding her wounds; let me get it for you," she said, then returned with copies of progress notes about other skin issues.
Asked when Resident #3 developed the pressure ulcers and whether interventions were in place to prevent them, the director said, "I wasn't here at that time. I will get the person that does the care plans."
Staff A, the facility's Care Plan Specialist, confirmed the failure during a subsequent interview. When asked if any interventions were ordered or in place to prevent Resident #3 from getting pressure ulcers, she searched her computer records.
"I see a care plan that was initiated on 04/22/25 that said she was at risk and is being treated for pressure ulcer," Staff A said. The date was significant — the care plan acknowledging risk was created only after the resident had already developed open wounds.
Asked whether anything existed prior to the resident developing pressure ulcers, Staff A was direct: "No I don't see anything care planned."
The timeline reveals a systematic failure in preventive care. Resident #3 entered the facility with documented buttock redness, lived for months with conditions that made pressure ulcers highly likely, received no preventive interventions, developed severe wounds, and only then received a care plan acknowledging her risk.
Federal inspectors classified this as a violation of regulations requiring facilities to provide appropriate pressure ulcer care and prevent new ulcers from developing. The level of harm was determined to be minimal harm or potential for actual harm, affecting few residents.
The inspection occurred following a complaint, suggesting someone outside the facility raised concerns about the quality of care. The resident's family, who said they were never informed about the initial redness, may have been among those who alerted authorities.
Resident #3's case illustrates how quickly preventable conditions can escalate when basic interventions are not implemented. What began as redness — easily treatable with repositioning, special mattresses, or other standard measures — progressed to severe, potentially life-threatening wounds requiring specialized medical treatment.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Palm Garden of West Palm Beach from 2025-12-29 including all violations, facility responses, and corrective action plans.