F-F585 - The center recognizes the guest/resident/legal representative/family has the right to voice grievances to the center without discrimination and without fear of reprisal. The center team members are responsible for making prompt efforts to resolve a grievance and to keep the guest/resident appropriately updated on the progress being made toward resolution. Definitions:
Prompt effort to resolve includes the center's acknowledgment of a grievance and to actively work toward a documented resolution of that grievance. Policy: The Grievance Official and Social Services personnel will serve as guest/resident liaisons/advocates in the concern grievance procedure.
1. The center will support the right of the guests/residents to file a grievance anonymously.
2. The center will make information available on how to file a grievance to the guest/resident/legal representative/family. This can be done by providing the information directly to the guest/resident and/or by posting the procedure in prominent locations throughout the center.
3. The name and contact information (business address and email address and business phone number) for
the Grievance Official will be posted in prominent locations throughout the center. The Grievance Official is
the Social Service Director/designee of the center.
4. The guest/resident has the right to file a grievance orally or in written format.
5. The center will make a prompt effort to resolve any grievance received. Grievances will be reviewed, investigated, resolved and documented in five days.
6. The center team members will immediately report all alleged violations involving neglect, abuse, injury of unknown origin, and/or misappropriation of guest/resident property following the center abuse prohibition policy.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 55 105733 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105733 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0585 7. The center will review with the guest/resident/legal representative/family the final resolution of the grievance. Level of Harm - Minimal harm or potential for actual harm 8. The guest/resident/legal representative/family have the right to obtain a written decision regarding the grievance. Residents Affected - Some 9. The center will maintain the grievance and any supportive documentation for a period of not less than 3 years.
Procedure: The Grievance Official and Social Services personnel will serve as resident liaisons/advocates in
the concern grievance procedure.
1. A grievance is defined as any formal expression (verbally or in writing) of interest regarding the well-being of a guest/resident.
2. Upon admission, the guest/resident/legal representative/ and family are informed of the right to voice grievances free from discrimination and/or reprisal.
a. This information will include the mechanism for voicing concerns/grievances and will be provided with a copy of the center's grievance policy, upon request.
3. A description of the grievance procedure for voicing concerns/grievances, either individually or anonymously, will be prominently posted throughout the center informing of the right to file a grievance either orally (spoken) or in writing.
4. The center will designate a Grievance Official with whom the grievance can be filed and will post his or her name, business address (mailing and email) and business phone number. Any team member can write, or assist in the writing of a grievance.
5. The Grievance Official is the Social Service Director/designee.
a. The Grievance Official is responsible for the following items: l . Overseeing the grievance process to include receiving and tracking grievances through to their conclusions to include the investigation, documentation of the summary and the follow up. 2. Leading any necessary investigations (including investigating responsibility for lost or damaged personal property to include dentures and eyeglasses). 3. Maintaining the confidentiality of all information associated with the grievance. 4. Coordinate with the center's Director of Quality Assurance, if the grievance meets criteria as an immediate reporting of alleged violation(s) involving abuse, neglect and/or misappropriation of guest/resident property. 5. The Grievance Official will close the grievance and reflect the conclusion/outcome of the grievance investigation or abuse investigation. 6. The Grievance Official will provide the guest/resident/legal representative with a written decision about the filed grievance upon request. 7. The grievances will be brought to the morning stand up meeting daily. They will be reviewed out loud with all the leadership team members. The grievance forms will come to the stand-up meeting daily until resolved. 8. The Grievance Official/designee will bring the Grievance Log monthly to the Quality Assurance and Performance Improvement (QAPI) meeting.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 55 105733 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105733 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0585 6. The center will make a prompt effort to resolve any grievance received. Grievances will be reviewed, investigated, documented and resolved within 5 business days. Every effort will be made to bring a Level of Harm - Minimal harm or resolution to the grievance. potential for actual harm 7. The contact information of independent entities with whom a grievance may be filed such as: State Survey Residents Affected - Some Agency, State Long-[NAME] Care Ombudsman program, or the Abuse hotline, will be posted in a prominent area of the center.
8. A designated area within the center for grievance collection will be identified so that each guest/resident/legal representative/family member may voice a concern anonymously or directly to the Grievance Official. a. Grievance forms will be available in the Social Service Department and may be returned to that office. They will also be available in other prominent areas of the center. (Social Service team members will maintain the stock in these areas). b. A grievance may be registered by telephone, mail,
a visit to a team member's office, visit or direct outreach to any team members. Guests/Residents who are unable to prepare a written grievance without assistance, may elect to receive support from any center team members or third party chosen by the guest/resident.
9. Below is a list of items that the investigating team member will include on the grievance form and the Grievance Official will be responsible to assure is completed when a written decision is requested. A written decision will only be provided by the Grievance Official/designee. a.The date the grievance was received. b.
The guest/resident name that is involved in the grievance. c. A summary of the guest/resident/legal representative/family grievance. (What is the grievance)? d. The steps that were taken to investigate the grievance. e. A summary of the pertinent findings or conclusions of the investigation regarding the grievance. f.A statement as to whether the grievance was confirmed or not confirmed. g. Documentation of any corrective action taken or to be taken by the center.
10. Upon receipt of the grievance, documentation on the grievance form will be initiated by the Grievance Official/designee or whichever professional team member receives the concern. Instructions for completion are outlined on the Addendum. a. The Grievance Official/designee will document the date the grievance is received on the Grievance Log and copies are made and distributed to the Executive Director and the referenced department representative. b. The Department Manager will initiate an investigation and complete
the applicable portion of the grievance form to record the investigative process and actions taken. C. After
the Department Manager completes the grievance form the signature and date areas must be completed. d.
The grievance reports will be reviewed by the Executive Director, the Grievance Official/designee to assure that the guest/resident's interests are addressed and the final disposition is identified, including the guest/resident/legal representative/family are satisfied with the outcome. e. The Executive Director signs the form in the designated area after the Final Deposition is recorded. All grievances forms will be reviewed and maintained by the Executive Director/designee.
11. The signature of the person initiating the grievance is not required. A guest/resident will not be subject to retaliation by any center team members because of the grievance or a recommendation for change.
12. The person filing the grievance has the right to expect the center will make prompt efforts to resolve grievances and, upon request, have the right to obtain a written decision regarding the grievance. a. Upon request for a written decision regarding the grievance, the Grievance
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 55 105733 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105733 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0585 Official/ designee will complete the Grievance Decision Notification of
Level of Harm - Minimal harm or Guest/Resident/Legal Representative/Family Grievance/Complaint/Concem and provide a copy to the potential for actual harm person initiating the grievance.
Residents Affected - Some 13. In the event that the grievance is not resolved to the satisfaction of all parties involved, the following options may be employed after an IDT/IPOC meeting is held: a. Contact Center Executive Director, Nursing and Social Service Directors meet and discuss possible further resolutions. b. Contact Regional Director and/or Consultants. c.Contact Ombudsman. d. Contact area AHCA Agency Office.
14. The Social Service Director/designee will record each Concern/Grievance Report on the Concern/Grievance Log for each month and submit it to the Executive Director. a. The Concern/Grievance reports will be kept together with the monthly log.
Group Grievances:
15. Group grievances generated in Resident Counsel meetings, or any other venue will be documented on
the grievance form by the guests/residents or their designee. The grievance will be provided to the Grievance Official and the grievance process described in this policy will be initiated. The Grievance Official will assist Life Enrichment in resolving group grievances that resulted from the resident counsel.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 55 105733 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105733 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0641 Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 34768 potential for actual harm Based on interview and record review the facility failed to ensure the Minimum Data Set (MDS) was accurate Residents Affected - Few related to discharge reason for one (#106) of 50 sampled residents.
Findings included:
Resident # 106 was admitted to the facility on [DATE REDACTED] and discharged on [DATE REDACTED]. Review of the Admission
Record showed the diagnoses included but not limited to fracture of right femur.
Review of the discharge MDS dated [DATE REDACTED] showed Section A, Identification Information showed discharge status to 04. Short-Term General Hospital.
Review of the progress notes dated 3/25/25 showed discharged to assisted living facility (ALF). Transported by ALF, sent with discharge instructions.
During an interview on 05/14/2025 at 5:47 p.m. the MDS RN, (Registered Nurse) stated the MDS showed
the resident was transferred to an acute hospital. She verified the progress note showed the resident was discharged to an ALF. The MDS RN stated the resident went to an ALF. The MDS RN stated the MDS had
an error and needed to be modified.
Requested and did not receive a facility policy on MDS accuracy expectations.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 55 105733 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105733 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0645 PASARR screening for Mental disorders or Intellectual Disabilities
Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49227 potential for actual harm Based on record review and staff interview, the facility failed to complete and or update the Pre-admission Residents Affected - Few Screening and Resident Reviews (PASARRs) for residents with a mental disorder and individuals with intellectual disability following qualifying mental health diagnoses for two (#12 and #6) of six residents reviewed for PASARRs.
Findings included:
1. Review of the admission record for Resident #12 showed the resident was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with primary diagnosis of dementia dated 9/22/24, and secondary diagnoses to include unspecified psychosis dated 9/21/20 and an adjustment disorder with depressed mood dated 6/17/21.
Review of a level I PASARR for Resident #12 dated 5/8/24 revealed the primary diagnosis of Dementia was not checked. The review showed the Level I PASARR was incomplete, and a level II was not submitted for consideration following qualifying diagnoses.
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2. A review of Resident #6's admission record revealed an initial admitted [DATE REDACTED] and a re-admitted [DATE REDACTED] with diagnoses to include an adjustment disorder with depressed mood.
A review of Resident #6's Preadmission Screening and Resident Review (PASARR), dated 8/31/2020, revealed there were no diagnoses marked under section I, mental illness (MI) or suspected MI.
On 5/13/25 at 2:13 p.m., an interview was conducted with the Nursing Home Administrator (NHA). She confirmed the level 1 PASARR for Resident #6 was not updated. She provided documentation showing the previous Director of Nursing (DON) attempted to update the level 1 PASARR, but did not submit it in the state vendor system. She said herself, the Director of Nursing (DON) and their corporate registered nurse (RN) are reviewing and updating PASARRs. She said all residents are screened for PASARRs upon admission to the facility. She said for those who are current residents they are reviewed during monthly psychiatry meetings. She said they review medications, new behaviors and/or diagnoses, then the PASARR is updated.
The NHA stated the facility did not have a PASARR policy. The NHA stated they follow federal and state vendor guidelines.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 55 105733 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105733 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49227
Residents Affected - Some Based on observation, interview and record review, the facility failed to revise patient-centered care plans for four (#81, #37, #33 and #76) out of twenty-nine residents reviewed.
Findings included:
1.
During an interview on 5/13/25 at 1:44 P.M. Resident #81 stated loud noises were a trigger for him and he completes self-calming exercises. The resident stated he went to a quiet place when he felt anxious.
A review of Resident #81's admission record showed an admitted [DATE REDACTED] with diagnoses to include bipolar disorder and Post Traumatic Stress Disorder (PTSD).
A review of Resident's # 81's Medication Administration Record, dated May 2025, showed orders for Bupropion twice daily for depression, Lamotrigine twice daily for mood.
A review of Resident #81's Trauma Informed Care Questionnaire (TICQ) dated 4/17/25, showed the resident had served in a war zone, thought his life was in danger and was seriously injured.
A review of care plan showed Resident #81 initiated on 4/17/25 showed the resident has a significant trauma exposure related to history of prior service in war zone/exposure to war-related casualties and history of a serious car accident. The goal showed Resident # 81 will state feeling safe in the facility environment through the next review date, revised on 4/30/25. The interventions included: address resident in a calm, quiet and respectful manner, offer resident information and encourage active participation in the development of the resident care plan, psychiatry, and psychological services consultation will be requested as needed and staff will attempt to ensure a consistent and predictable routine for resident care and minimize unexpected changes.
A review of Resident # 81's admission Minimum Data Set (MDS) dated [DATE REDACTED], showed Section C, cognitive patterns Brief Interview for Mental Status Score (BIMS) of 15, indicating intact cognation. Review Section D, mood showed feeling down, depressed, or hopeless occurred 2 to 6 days.
A review of Resident# 81's psychological evaluation dated 5/8/25 showed the resident's emotional functioning is sufficient to alter his baseline functioning and therefore, treatment is medically necessary. The resident may benefit from individual therapy to help reduce symptoms of depression.
A review of Resident #81's visual/bedside Kardex (a document used by staff with care instructions specific to each resident) Report as of 5/15/25, sections related to safety, monitor, resident care, did not include trauma related care interventions.
During an interview on 5/14/25 at 8:05 A.M. Staff M, Registered Nurse (RN) assigned to Resident #81 said
she did not know if any of her residents had a PTSD diagnosis.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 55 105733 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105733 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0657 During an interview on 5/14/25 at 2:35 P.M. with the Social Services Director (SSD) and the Social Service Assistant (SSA), the SSD said she completed Resident #81's TICQ on admission and does not recall what Level of Harm - Minimal harm or was on the form. The SSD stated the care plan including the interventions are initiated based on the potential for actual harm residents' response to the questions.
Residents Affected - Some During an interview on 5/15/25 at 8:50 A.M. with Resident #81 and the SSD. Resident #81 said when he woke up in the mornings his anxiety level is at a 5. The SSD said, he does not have any triggers.
The review of the care plan dated 4/17/25 and interview with SSD revealed Resident #81 was not assessed or care planned for triggers or retraumatization.
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2.
On 5/12/25 at 2:34 p.m., Resident #37 was observed lying down in bed. An observation of her hands, over
the blanket, revealed her nails were approximately 1-1.5 inches long. She said she did not like them like that. Resident #37 was observed attempting to hide her hands and stated, I'm sorry they are like that. If they would give me something to cut or file them I would do it.
On 5/14/25 at 9:48 a.m., an observation of Resident #37 revealed the same concerns observed on 5/12/25.
On 5/14/25 at 9:49 a.m., an interview was conducted with Staff V, Certified Nursing Assistant (CNA). He confirmed Resident #37 was one of his assigned residents. He said nail care was provided on Sundays or on
the residents' shower days. Staff V, CNA said there was a book at the nurse's station with resident's shower times and assigned days.
A review of Resident #37's admission record revealed an admitted [DATE REDACTED]. Further review of the admission
record revealed diagnoses to include anxiety disorder, unspecified, unspecified psychosis not due to a substance or known physiological condition, major depressive disorder, recurrent, unspecified, repeated falls, adult failure to thrive, and personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits.
A review of Resident #37's progress notes from 12/2024 to 5/15/25 revealed there was no documentation related to nail care to including cutting, trimming,filing or refusals.
A review of Resident #37's tasks related to shower and bath days in the last 30 days revealed the following, Shower: Tuesday and Friday 3-11. A review of documented tasks revealed she received a shower on 4/22/25 and 4/29/25. A review of documented tasks revealed she received a bed bath on 4/18/25, 5/2/25, 5/6/25, 5/9/25, and 5/13/25. The review did not show the resident was offered nail care.
A review of Resident #37's care plan revealed the following:
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 55 105733 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105733 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0657 - [Resident name] has ADL [activities of daily living] Self-Care and mobility deficit. She needs assistance with bathing, dressing, transfers and toileting related to weakness Date Initiated: 03/02/2022, Revision on: Level of Harm - Minimal harm or 06/12/2023, with interventions to include, Bathing preference shower and/or bed bath, BATHING- Total potential for actual harm ASSIST x1 [1 person] GROOMING- Total Assist x1. Further review of the care plan revealed no documentation related to refusing nail care or preferring long nails. Residents Affected - Some
On 5/15/25 at 10:20 a.m., an interview was conducted with Staff O, CNA. She said she provided nail care including washing and cutting residents' nails. She said nail care is provided every day or as needed. Staff O, CNA said she followed the resident's care plan regarding nail care, such as preferences for their nails being cut.
On 5/15/25 at 2:40 p.m., an interview with Staff P, Registered Nurse (RN)/Unit Manager (UM) was conducted. She stated nailcare is provided, Whenever it's needed. You can do nailcare if you walk by a resident whose nails are long and during their shower. She said a couple of weeks ago she started implementing that staff should look at the residents' nails after dining, such as cleaning them, when they put
the resident in bed. She stated, It's on-going education and reminders. Staff P, RN/UM said Resident #37 was very picky and, It's a hit or miss, with nail care. She said, She likes them long as it's part of who she is. Staff P, RN/UM confirmed Resident #37's refusals for trimming her nails/preference for long nails is not in her care plan and stated, It should probably be documented.
48223
3.
On 05/12/25 at 09:53 AM Resident #33 was observed lying in bed in a facility gown, just above resident elbow on the right upper extremity red circular spots were noted. Resident stated having a rash that was extremely itchy. Resident continued this is much better, the physician visited and prescribed a cream the facility has been applying.
Review of the Admission Record showed Resident #33 was admitted to the facility on [DATE REDACTED] with diagnoses that included but not limited to Generalized Anxiety Disorder, and Major Depressive Disorder.
Review of Resident #33's Minimum Data Set (MDS) most recent quarterly assessment dated [DATE REDACTED] revealed resident is cognitively intact, with a Brief Interview for Mental Status (BIMS) of 15/15.
Review of Resident #33's Dermatology Provider Note dated 04/24/2025 revealed new resident to be seen per administration to rule out contagion. Diagnoses included but not limited to: Rash and other nonspecific skin eruption; Pruritus, unspecified; Xerosis cutis; Atrophic disorder of skin, unspecified. Assessment: . on examination, the patient is noted with a rash to the right chest, a scrape biopsy was performed to the right chest, patient tolerated well. Wound care is managing the patient's buttocks. Patient presents for evaluation of rash the rash is described as erythematous and patient reports pruritus. Medications order: Triamcinolone Acetonide 0.1% External Cream start 4/24/2025.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 55 105733 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105733 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0657 Review of Resident #33's Care Plan showed: Focus - At risk for alteration and skin integrity related to: Edema, Fragile skin, Use of blood thinning medications and incontinence. revised 01/01/2025. The Goal: * Level of Harm - Minimal harm or intact skin will remain intact through next review, revised 2/17/2025; * lateral lower extremity dyskeratosis will potential for actual harm be managed with treatment in place for 30 days date initiated 2/13/2025; * MASD [Moisture-Associated Skin Damage] to bilateral buttocks will improve with treatment in place date initiated 3/20/2025;* left inner thigh Residents Affected - Some will resolve with treatment in place they initiated 5/9/2025; * wound to sacrum will improve with treatment in place date initiated 5/12/2025; * left breast fold will resolve with treatment in place 5/14/25 treatment updated for 10 days revised on 5/15/2025.
The care plan did not show any interventions related to the the new rash on the resident's arm and chest on 4/24/2025.
4.
During an interview on 5/12/25 at 2:35 PM Resident #76's responsible party (RP) stated not seeing hydration
in Resident #76's room when visiting, especially in the evening. The RP stated being concerned that going from dinner to breakfast with no liquids was concerning. The RP stated bringing the concern to the facility on multiple occasions but the concern continues.
During multiple observations of Resident #76's room on 05/12/25 at 2:03 PM, 05/13/25 at 5:36 PM, and on 05/14/25 at 1:09 PM there were no cups or liquids in room.
Review of Resident #76's admission record showed Resident #76 was admitted to the facility on [DATE REDACTED] with
a diagnosis that included but not limited to Cerebral Infarction (stroke), hypertension, and other comorbidities.
Review of Resident #76's quarterly Minimum Data Set (MDS) dated [DATE REDACTED] indicated the resident had a Brief Interview for Mental Status (BIMS) score of 00 out of 15 which indicated severe cognitive deficits and resident is dependent on staff for Activity of Daily Living (eating and drinking).
Review of Resident #76's Order Summary Report with active physician orders as of 05/15/25 showed: REGULAR diet, Pureed texture, Honey Thickened Fluids consistency 10/16/24 - revised 12/17/24.
Review of Resident #76's Speech Therapy (SLP) Discharge Summary dated 4/5/2025 revealed diagnosis of Dysphagia and Recommendations not limited to: Nectar thick liquids (NTL), drink from cup only, check mouth for pocketing or residue after intake; alternate solids and liquids during meals, and close supervision.
Review of Resident #76's Care Plan showed: Focus - Resident is at nutritional risk related to CVA [stroke], hypertension on mechanically altered diet 12% loss x 60 days. BMI [body mass index] greater than 19. 6.2% gain x 10 days BMI 19.6, within normal limits. BMI 18.7, within normal limits, -5.7% x 30, intake 76 to 100% most meals. Add large portions meat/meat alternate at meals. revised on 12/11/2024. The goal Resident will tolerate food/liquid consistency and have no significant weight change through review period, revised on 2/19/2025. Interventions: fortified foods with meals revised on 3/5/2024; monitor labs as ordered initiated 1/30/2024; Provide adaptive equipment as ordered scoop plate with meals revised on 5/28/2024; serve diet as ordered date initiated 1/30/2024; Weight per facility protocol revised on 2/19/2024.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 55 105733 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105733 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0657 Review of this care plan revealed there were no interventions for swallowing or swallowing precautions.
Level of Harm - Minimal harm or During an interview on 05/15/25 at 11:09 AM the MDS Coordinator confirmed the resident #33's care plan potential for actual harm was not updated to reveal the treatment for the rash. The MDS Coordinator continued to state Resident #76's care plan did not reveal a swallowing issue the only care plan was related to nutrition and showed to Residents Affected - Some follow the physician orders.
During an interview on 05/15/25 at 11:53 AM the Director of Nursing (DON) stated the expectation is for the care plan to be updated when new issues are treated/updated. The DON continued to review the care plan for Resident #76 and confirmed the care plan did not specifically indicate what the problem is for Resident #76 related to the swallowing.
Review of an undated facility policy titled Person-centered Comprehensive Care Plan revealed:
Guideline: It is the practice of the center to develop and implement a person-centered comprehensive care plan that includes measurable objectives and timeframes to meet their preferences and goals, and address
the guest/resident's nursing, medical, physical, mental, and psychosocial needs. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each assessment, including both comprehensive and quarterly review assessments and with significant changes in the guest/resident's condition. The interdisciplinary team will work collaboratively with the guest/resident, responsible party and/or family members to develop a comprehensive person-centered care plan that encompasses each guest/resident's personal preferences, goals, and objectives. The comprehensive person-centered care plan will be developed based on the Minimum Data Set (MDS) to assess the guest/resident's clinical condition, cognitive and functional status, and use of services. The comprehensive care plan will address the following: -Services to be furnished to attain or maintain the guest/resident's highest practicable physical, mental, and psychosocial well-being. -Needs and Strengths of the guest/resident. -Culturally Competent Care and Services/Preferences . -Guest/resident's refusal of care or services and center's action to provide education to guest/resident and/or representative.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 55 105733 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105733 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable.
Level of Harm - Minimal harm or 48223 potential for actual harm Based on observation, interview and record review, the facility failed to ensure personal hygiene needs were Residents Affected - Few provided to one (#76) of two dependent residents sampled for Activities of Daily Living (ADL).
Findings included:
1. On 05/12/25 at 02:03 PM Resident #76 was observed sitting in his specialty wheelchair with whiskers (long stiff hairs) growing on his face and food particles on his face and down his shirt.
During an interview on 05/12/25 at 02:36 PM Resident #76's Responsible Party (RP) stated frequently finding Resident #76 unshaven and has informed the facility on multiple occasions of resident's preference to be shaved. The RP confirmed Rsident #76 was dependent on staff to complete ADLs.
On 05/13/25 at 05:36 PM Resident #76 was observed lying in bed with whiskers growing on his face.
Review of Resident #76 clinical record revealed the resident was a long term care resident with diagnosis that included cerebral infarction (stroke) and contracture of right wrist/hand.
Review of the Resident #76's most recent quarterly Minimum Data Set (MDS) Assessment, dated 05/02/2025, revealed the resident was coded as a '00' for the Brief Interview for Mental Status, indicating the resident had severe cognitive impairment. The resident was coded as being dependent on staff for personal hygiene needs, which included facial grooming and cleaning.
Review of the resident's care plan dated 01/26/2024 revealed a problem of ADL - Activities of Daily Living - Self Care and Mobility Deficit. Resident needs assistance with ADL's and is at risk of developing complications associated with decreased ADL self-performance related to right sided weakness.
During an interview on 05/13/25 at 11:42 AM with Staff G, Certified Nursing Assistant (CNA) stated residents are provided facial grooming on shower days only and yes residents can develop whiskers in between showers. Staff G, CNA stat Resident #76 did not have any behaviors and did not have concerns when providing care for the resident. Staff G confirmed Resident #76 had significant whiskers.
During an interview on 05/15/25 at 09:41 AM with Staff P, Registered Nurse (RN)/Unit Manager (UM) stated CNAs should provide facial grooming related to shaving everyday. Staff P, RN/UM stated ithe resident had a clean shave preference. Staff P stated the resident should be assisted with cleaning of the face and hands
after all meals and as needed throughout the day.
A policy related to ADLs for dependent residents was not received.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 55 105733 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105733 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0688 Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48223
Residents Affected - Few Based on observation, interview, and record review the facility failed to ensure devices for contracture prevention were provided as ordered for two (#76 and #82) of two residents sampled.
Findings included:
1.
Multiple observations were conducted of Resident #76 without splints and braces. On 05/12/25 at 2:03 PM Resident #76 was observed in room seated in a wheelchair without any splints or braces on upper extremities. On 05/13/25 at 5:36 PM, Resident #76 was observed in bed without any splints or braces on upper extremities. On 05/14/25 at 9:15 AM, Resident #76 was observed in the day room seated in a wheelchair without any splints on. On 05/14/25 at 1:09 PM, Resident #76 was observed in his room seated in
a wheelchair without any splints on. On 05/14/25 at 3:15 PM, Resident #76 was observed in bed sleeping without any splints on. On 05/14/25 at 5:32 PM, Resident #76 was observed in bed awake, without any splints on.
During an interview on 5/12/25 at 2:35 PM Resident #76's family member stated they had not seen Resident #76 with splints on right hand. The family member stated visiting at various times and days. Family member stated mentioning this several times to the facility and they do not do anything. The family memeber said, Recently, I gave them a list of concerns at the care plan meeting related to Resident #76, and worsening of right wrist contracture was one of the concerns.
Review of Resident #76's admission record showed Resident #76 was admitted to the facility on [DATE REDACTED] with
a diagnosis that included but not limited to Cerebral Infarction (stroke), hypertension, and other comorbidities.
Review of Resident #76's quarterly Minimum Data Set (MDS) dated [DATE REDACTED] showed the resident had a Brief
Interview for Mental Status (BIMS) score of 00 out of 15 which indicated severe cognitive deficits. Section E Behaviors shows resident does not exhibit any behaviors. Section GG Functional Abilities showed the resident was totally dependent on staff for all Activities of Daily Living (ADLs), had impairments to one side, both upper and lower extremities. Section O Special Treatments, Procedures, and Programs showed the resident does not have a splint or brace.
Review of Resident #76's Order Summary Report with active physician orders as of 05/15/25 showed: Order start date 6/13/24, Passive range of motion (ROM) to right hand/gentle stretching to right hand and wrist. Apply right [brand name] resting hand splint. Wear as tolerated, may be removed for care and laundering.
Review of Resident #76's Occupational Therapy (OT) Discharge Summary dated 4/5/24 showed the following discharge recommendations: Contracture management program as written. Resident #76 made consistent progress throughout treatment plan of wearing splint.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 55 105733 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105733 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0688 Review of Resident #76's care plan initiated on 1/26/24 revealed the resident did not have a care plan in place related to contracture management. The care plan showed an ADL Self-Care and mobility deficit. Level of Harm - Minimal harm or Resident needs assistance with ADL's and is at risk of developing complications associated with decreased potential for actual harm ADL self performance related to right sided weakness Date Initiated: 01/26/2024 Revision on: 01/26/2024 with the following interventions: Daily after a.m. (morning) care, passive ROM to right hand/gentle stretching Residents Affected - Few to right hand and wrist. Apply right [brand name] resting hand splint. Wear as tolerated, may be removed for care and laundering. Date Initiated: 04/05/2024. If Resident #76 is noted to remove splint attempt to reapply Date Initiated: 08/28/2024.
Review of the care plan showed Resident #76 did not have a care plan in place related to behaviors or refusing care.
Review of Resident #76's nursing progress notes from January 2025 to May 2025 confirmed there were no documented behaviors or refusal of care.
During mulptiple interviews related to Resdient #76 conducted on 05/14/25, Staff G, Certified Nursing Assistant (CNA), Staff D, CNA, and Staff H, CNA all confirmed caring for Resident #76 regularly and stated
the resident was cooperative and did not wear any splints. They stated the resident did not have behaviors. Staff H, CNA stated if a resident needed splints it would be in the computer or the resident would just request
the splint.
During an interview on 05/14/25 at 05:47 PM Staff I, Licensed Practical Nurse (LPN) stated being familiar with Resident #76. Staff I, LPN stated the resident did not have behaviors, did not refuse care and stated
they were not aware of splint usage. Staff L could not recall seeing the resident with splint on. Staff I, LPN stated if a resident had orders for splint or ROM the nurse is responsible to check the box and the CNAs should complete this task
During an interview on 05/15/25 at 09:10 AM Staff E, CNA stated Resident #76 does not wear a splint.
During staff interviews on 05/15/25 09:23 AM Staff F, LPN stated they were not aware of Resident #76 having a splint order. Staff F, LPN stated if resident had an order the CNAs carry this order out and the nurse checks the box.
2.
During an interview and observation on 05/12/25 at 2:03 PM, Resident #82 was lying in bed no splint observed on hand stated no one has put on my splint since being discharged from OT, it sits in a box on the dresser.
During an interview on 05/13/25 at 9:22 AM Resident #82 stated the splint was not offered or applied last night.
Review of Resident #82's admission record showed Resident #82 was admitted to the facility on [DATE REDACTED] with diagnoses to include atrial fibrillation and contracture of the right hand.
Review of Resident #82's admission Minimum Data Set (MDS) dated [DATE REDACTED] indicated the resident had a BIMS score of 15 out of 15 which indicated no cognitive deficits.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 55 105733 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105733 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0688 Review of Resident #82's Order Summary Report with active physician orders as of 05/15/25 showed: Order start date 4/24/2025, Apply right hand splint at hours of sleep. Remove in AM for ADL's as tolerated. Check Level of Harm - Minimal harm or skin for integrity with application and removal potential for actual harm
Review of Resident #82's care plan showed an ADL Self-Care and mobility deficit - Resdient needs Residents Affected - Few assistance with ADLs and is at risk of developing complications associated with decreased ADL self-performance related to disease process/condition, recent surgery, Weakness Date Initiated: 6/27/2024 with the following interventions, apply right hand splint at hours of sleep. Remove in a.m. Skin checks when applying and removing. To be worn as tolerated. Resident is able to remove independently. Date initiated 4/25/2025
Review of Resident #82's Splinting and Wheelchair Positioning Program dated 4/14/2025 revealed: the therapist's name who completed form, trained nursing and wrote: precautions - Check skin before and after application and notify therapy with any issues. Under the section Instructions and Adaptive Equipment: 1. Place hand splint into hand. 2. Wrap wrist strap and secure Velcro. 3. Gently straighten the ring and little finger within patients' tolerance. 4. Strap finger to Velcro. Note: Patient is able to remove himself and its okay if he does. To be worn as tolerated. Remove for care. A picture of the device on the resident is shown. Physicians Order to Say: Apply right hand splint at hours sleep. Remove in am for ADLs as tolerated. Provide skin checks.
During an interview on 05/15/25 at 09413 AM Staff P, Registered Nurse (RN)/Unit Manager (UM) stated the CNAs put the splints on and they have instructions in the room. The Treatment Administration Record (TAR) has the order. The nurse check mark would indicate the nurse completed the task. If the resident refused the splint or ROM, then the nurse would need to indicate that in the TAR and document. Staff P, RN stated Resident #76 and Resident #82 both had hand splints. Staff P stated Resident #82 needed assistance with placing the hand splint on and does not know why it was not being put on the resident.
During an interview on 05/15/25 at 11:53 AM the Director of Nursing (DON) stated the expectation is for the CNAs to place the resident splints on. The DON stated the nurse is responsible for completing the ROM.
Review of an undated facility policy titled SPLINT and BRACE Program showed: Splints are to be worn according to the schedule outlined in the referral from therapy that then placed in tasks and the Kardex. Therapy will train the CNAs and nursing team members how to put the device on and off with the specifics
on the splinting program form. Each guest or resident with a splint will have a splint box or designated splint storage container when it is not in use. It should be labeled with the resident/guest's name and located in their room. The splinting program form will be stored in the top of the splint box for reference and any other place deemed appropriate by the center IDT (Interdisciplinary Team). Cleaning of the splint should be done according to manufacturer's guidelines. Always examine the resident/guest for red areas, pain, change in skin integrity, rash, ill fit, etc. Should something be observed when applying or removing the splint, notify the nurse and therapy immediately and do not put it on until directed to do so.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 55 105733 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105733 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0688 Review of the facility's policy titled Restorative Functional Maintenance Nursing Program with a revision date of May, 2022 showed: The therapy department plays an important role in the Nursing Restorative/Functional Level of Harm - Minimal harm or Maintenance programming by providing resident screening for needs and assisting with the development of potential for actual harm the restorative plan as needed. Follow up review of progress may also be provided by the therapist at regular intervals as needed. Should the resident experience lack of anticipated progress toward restorative goals or Residents Affected - Few have a significant change in functional ability, the Restorative Nurse may refer the resident back to the therapist. Nursing restorative/functional programming may include, but is not limited to: Active and/or passive Range of Motion, Splint or brace assistance.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 55 105733 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105733 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 34768
Residents Affected - Some Based on observation interview and record review the facility failed to provide an environment free from falls and failed to ensure documentation of assessments and neurological checks post fall, for three (#93 #11 and #10) of three residents sampled.
Findings included:
1.
On 05/14/2025 at 8:41 a.m. Resident #93 was observed sitting at her bedside. She was not eating her breakfast. When greeted, she stated, not good. She turned her back and would not engage in conversation.
Resident #93 was admitted on [DATE REDACTED] and readmitted on [DATE REDACTED]. Review of the Admission Record showed diagnoses included but not limited to pneumonia, End Stage Renal Disease (ESRD), gastrostomy, adult failure to thrive, diabetes, dependent on renal dialysis, muscle weakness, difficulty in walking, anemia, Cerebrovascular Accident (CVA), hypertension, cardiac pacemaker, depression, atrial fibrillation, generalized anxiety disorder. Review of the admission, Minimum Data Set (MDS) dated [DATE REDACTED] showed Brief Interview for Mental Status (BIMS) score of 15 or cognitively intact. Section GG, Functional Abilities showed resident required partial to moderate assistance with toileting and showering. Section O, Special Treatments, Procedures, and Programs showed resident was on dialysis.
Review of the progress notes revealed the following:
On 05/13/25 at 11:42 a.m. Interdisciplinary Note (IDT) note showed Resident was discussed with IDT team post incident (fall). Resident verbalized she was trying to self-transfer to wheelchair with ultimate goal of using restroom. Right shin abrasion noted, resident denied impact to head during event or delayed pain/discomfort. Resident education provided post event was regarding call light utilization, resident's physical limitations, and the importance of using the Wheelchair (w/c) brakes. Return demonstration shows effectiveness as well as verbal understanding. Resident was own responsible party and verbalized no call out needed at this time.
On 05/13/2025, Fall Risk Evaluation showed a score of 17.0 meaning the resident was at risk for falls.
On 05/12/2025, a Change in Condition (CIC) / SBAR (Situation, Background, Assessment, Recommendation), showed Falls, Nursing/observations, evaluation, and recommendations are: Heard someone calling out help me. Discovered resident laying on floor on her back with w/c (wheelchair) behind her, noted w/c brakes were not on, asked resident what happened stated I was trying to go to the bathroom, and I forgot to put my brakes on and fell . Primary Care Provider Feedback: none at this time. Reminders given to resident to ask for assistance.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 55 105733 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105733 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689 Review of the care plans showed Resident #93 was at risk for falls related to unsteady gait/balance as of 04/16/2025. Interventions included but not limited to encourage appropriate footwear as of 04/16/2025; place Level of Harm - Minimal harm or items used in easy reach and PT and OT to screen prn (as needed). potential for actual harm
Review of resident #93's electronic medical record (EMR) revealed neurological checks were not Residents Affected - Some documented. Post fall neurological checks were requested and they were not provided.
During an interview on 05/14/2025 at 4:08 p.m. Staff B, Licensed Practical Nurse/Unit Manager (LPN/UM) reviewed Resident #93's medical record for the 05/02/2025 fall. Staff B verified there was not a progress note regarding the fall including a description of the fall, and the assessment of the resident in the medical record. Staff B stated only a facility form was filled out. Staff B was unable to locate the neurological checks.
2.
On 05/14/2025 at 8:42 a.m. and at 3:49 p.m. Resident #11 was observed sleeping in her bed. The bed was
in low position.
Review of the Admission Record for Resident #11 revealed and admitted [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses included but not limited to atrial fibrillation, Chronic Obstructive Pulmonary Disease (COPD), pulmonary fibrosis, diabetes, muscle weakness, difficulty in walking, unsteadiness on feet, heart failure, cognitive communication deficit, osteoporosis, pathological fracture, myasthenia gravis without exacerbation, Altered Mental Status, cardiac pacemaker, dementia, hypertension, and cardiomegaly.
Review of the MDS dated [DATE REDACTED] showed resident #11 had a BIMS score of 13, meaning cognitively intact. Section GG, Functional abilities showed she required partial/moderate assistance for toileting and showering.
Review of progress notes revealed the following:
On 04/18/2025 at 7:29 p.m. spoke with resident's [family member] regarding an unwitnessed fall. Vital signs stable. Small cut on right side of face. No complaints of pain. Doctor paged and made aware.
On 04/20/2025 at 3:52 p.m. a Fall Risk Evaluation was performed revealing a score of 12 meaning the resident was at risk for falls.
Review of an Advanced Registered Nurse Practitioner (ARNP) note dated 04/23/2025 showed facility staff requesting evaluation as resident had an unwitnessed fall at the end of last week. Resident does not appear to have injured herself, but they are stating that she was experiencing some increased back pain. Resident has a history of chronic pain as well as multiple old compression fractures to her lumbar and thoracic spine. Resident was seen and examined sitting up in the common area eating lunch, no other distress. Stated she started to feel better today. She denied specific complaints of chest pain, shortness of breath, nausea/vomiting, fever. She stated that her pain has been managed with her current pain medications.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 55 105733 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105733 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689 A progress note on 05/08/2025 at 2:30 a.m. showed - Resident got up into wheelchair with assist of one person. She complained of severe pain in her back and hard to breathe. Resident said, It's hurting so bad, 8 Level of Harm - Minimal harm or on a scale of 1 to 10. Her blood pressure was 130/94, pulse 75. Administered Morphine Sulfate 0.25 ml and potential for actual harm Lorazepam 0.25 ml as per doctor's orders. Resident did not want ice on her back. Staff did massage back for10 minutes with minimal relief. Will continue to monitor for pain meds to work. Residents Affected - Some
On 05/08/2025 at 6:59 a.m. nurse called and spoke to [family member] and also notified hospice that resident had been transported to hospital for fall.
On 05/08/2025 at 7:13 a.m., Change in Condition / SBAR for fall occurred in the morning, blood pressure showed 150/74 at 3:11 a.m., pulse 76 for 05/06/2025 at 3:07 p.m., respirations 19 on 05/08/2025 at 3:11 a. m. oxygen saturation 95% on 05/06/2025 at 3:07 p.m. Primary Notification on 05/08/2025 at 6:30 a.m. Recommendation to send resident out per request. Resident / Representative Notification of [family member] hospice and doctor on 05/08/2025 at 6:31 a.m.
The Change in Condition / SBAR documented for 05/08/2025 fall did not include a description of the fall event and/an accurate assessment of the resident's status.
On 05/08/2025 at 11:22 a.m. Resident returned to facility. Discoloration noted to bilateral lower extremities as well as bilateral upper extremities. CT (Computed Tomography) scans of head and c-spine were negative. Chest and pelvic x-ray negative for acute injury as well. [family member] at bedside upon return. Resident expresses discomfort. Floor nurse made aware and will follow. Call light placed within reach and bed placed
in lowest position.
On 05/09/2025 physician note showed the resident seen today for medication management, CHF, multiple ecchymosis and right head hematoma. Resident was seen in bed and appeared comfortable. Chart reviewed and resident had a fall on 05/08/2025. She was sent to the hospital ER (emergency room ) for evaluation per her request. Resident returned later the same day to facility where she resides for long term care. Nurse reports resident was refusing pills (medications). No other concerns per nurse and plan of care was reviewed.
An IDT progress note dated 05/09/2025 at 9:59 a.m. showed - Resident discussed with IDT team post incident. Resident recently admitted to Hospice care with diagnoses of ASHD (Atherosclerotic Heart Disease). Overall decline was noted. Resident appeared to be trying to get ready for the day. Care plan updated for during last rounds on 11 p.m. -7 a.m., staff to offer assistance with a.m. ADL care to prevent resident from self-ambulating for a.m. set up. Notify nurse for documentation if resident refuses at that time and continue to re-offer throughout a.m. Referral to therapy placed. [Family member] made aware of care plan changes. No delayed injury noted. Imaging in ER negative for acute injury.
Review of the record showed on 05/09/2025 at 10:47 a.m., a Fall Risk Evaluation showed resident had a score of 14.0 meaning the resident was at risk for falls.
Review of resident #11's electronic medical record (EMR) revealed neurological checks were not documented. Post fall neurological checks were requested and were not provided for the 04/18/2025 fall.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 55 105733 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105733 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689 There was no Change in Condition/SBAR documented for the fall on 04/18/2025. There was no assessment of the fall including description of event and assessment of the resident's status. Level of Harm - Minimal harm or potential for actual harm Review of the care plans showed Resident #11 was at risk for falls related to weakness and unsteady gait as of 01/19/2023 and revised on 05/08/2023. Interventions included but not limited to during last rounds on 11 p. Residents Affected - Some m. -7 a.m., staff to offer assistance with a.m. Activities of Daily Living (ADL) care to prevent resident from self-ambulating for a.m. set up as of 05/09/2025; 11 p.m. -7 a.m. shift to offer toileting throughout the overnight hour to discourage self-transfers as of 11/18/2024; encourage appropriate foot wear as of 01/19/2023; Place items within easy reach as of 01/19/2023.
During an interview on 05/14/2025 at 3:54 p.m. Staff A, RN reviewed the documentation for Resident #11 RN verified there was no documentation or complete documentation regarding the 04/18/2025 fall nor 05/08/2025 fall in the medical record.
During an interview on 05/14/2025 at 4:08 p.m. Staff B, LPN, UM stated she reviewed the medical record for Resident #11 regarding the 04/18/2025 fall. Staff B stated there was not a progress note regarding the fall. Staff B stated the staff did a Fall Risk Evaluation only. Staff B stated they referred the resident to therapy. Staff B stated there was no description of the fall in the medical record. She stated neurological checks are required for an unwitnessed fall. Staff B,LPN stated they perform neurological checks on paper. Staff B stated related to the 05/08/2025 fall, they sent the resident to the hospital. She stated the Change In Condition / SBAR just documents fall. Staff B, LPN confirmed there was no description of the fall in the Change in Condition nor was there a progress note.
3.
On 05/14/2025 at 8:3 a.m. Resident #10 was lying in bed with the head of the bed elevated. Floor mats were
in place. Her bed was in a low position.
Resident #10 was admitted on [DATE REDACTED]. Review of the Admission Record showed diagnoses included but not limited to COPD, cognitive communication deficit, muscle weakness, difficulty in walking, history of falling.
Review of the MDS dated [DATE REDACTED] showed BIMs score of 08 or moderately impaired. Section GG Functional Abilities showed Resident #10 required maximum assistance for toileting and showering.
Review of the progress notes showed the following:
On 04/02/2025 at 8:53 p.m. Fall Risk Evaluation was performed with a score of 4.0 meaning the resident was at not at risk for falls.
On 04/02/2025 at 10:18 p.m. resident found on floor in sitting position next to bed. Normal Range of Motion. No injuries or complaints of pain. Vitals within normal limits. Doctor and family notified. Change in Condition / SBAR performed.
On 04/02/2025 at 10:23 p.m. a Change in Condition / SBAR for fall was documented.
On 04/03/2025 at 7:45 a.m. a Fall Risk Evaluation was performed with a score of 23 meaning the resident was at risk for falls.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 55 105733 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105733 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689 A Change in Condition / SBAR for fall dated 04/08/2025 at 7:15 p.m. showed - Aide notified this nurse resident was sitting on floor beside bed. Resident alert and oriented x 3. Vitals within normal limits. Resident Level of Harm - Minimal harm or denied injury. No notable injuries. Resident stated she was trying to get up to take self to bathroom and slid potential for actual harm off bed onto floor. Bed was in low position, call light within reach, but call light was not on. Resident assessed, no injury, assisted up on to bed and then to wheelchair and assisted to bathroom. Resident Residents Affected - Some educated to use call light for assistance. Primary Care Provider responded with the following feedback: no new orders.
On 04/09/2025 Resident discussed with IDT team post incident. Resident trying to ambulate to restroom without assistance. It was noted she was toileted less than 2 hours prior. Resident verbalizes no delayed pain/discomfort. Care plan reviewed and updated for Palm Program and low bed while in bed. Attempt to call out to family in regards. Line disconnected. Social services made aware.
An IDT progress note dated 04/11/2025 showed Resident #10 was discussed with IDT team post fall. No delayed injury noted, and resident verbalizes no pain/discomfort. Resident noted to have been toileted within
an hour prior to incident. Discovered sitting on floor against bathroom door with brief off. Resident verbalized
she is aware she did not use her call light. Resident education provided regarding call light usage as well as severity of falling and risk for major injury. Understanding noted and returned demonstration appears effective. Per resident [family member] has been called enough and she preferred no call out in regard to education. Per nurse [family member] also has been giving resident verbal encouragement regarding call light usage. Referral to therapy placed as well.
A Change in Condition / SBAR for fall dated 04/16/2025 at 12:45 a.m. showed - Blood pressure on 04/16/2025 at 1:15 a.m. 119/81; pulse 106 04/16/2025 at 1:15 a.m.; respiration 18 on 04/16/2025 at 1:15 a. m. Resident was found by aide on floor next to bed in a prone position trying to crawl. When this nurse asked
the resident what she was doing she stated she was trying to go to the bathroom. Call light was not on but in resident's reach. Bed was in low position. Notified doctor that resident had behaviors earlier showing aggression toward staff and difficult to re-direct. Also notified this was third fall in two weeks. Doctor ordered resident to be sent to the ER for further evaluation and CT scan. Primary Care Provider responded with the following feedback: Send to ER for CT scan and evaluation.
Further review of progress notes revealed the following:-
On 04/16/2025 at 6:38 a.m. Resident returned from hospital with a sprained right ankle. Splint on ankle. Follow up with orthopedic.
On 04/16/2025 at 6:42 a.m. doctor and family notified of resident returning.
On 04/16/2025 at 11:02 a.m. Fall Risk Evaluation was performed with a score of 26.0 meaning the resident was at risk for falls.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 55 105733 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105733 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689 An IDT progress note dated 04/16/2025 at 11:12 a.m. showed - Resident discussed with IDT team post incident (fall). Resident returned from ER with diagnosis of right ankle sprain. Splint/brace in place. Resident Level of Harm - Minimal harm or verbalizes no discomfort this a.m. Per investigation, resident toileted less than 2 hours prior during 1st potential for actual harm rounds of 11 p.m. -7 a.m. shift. Resident verbalized trying to go to closet to get clothes. Confusion noted. Care plan reviewed and updated for bilateral floor mats while in bed. Referral to therapy placed. Nurse Residents Affected - Some Practitioner in house and reviewing medications for possible adjustment. Risk Manager called family in regards to fall. Family verbalized understanding regarding care plan changes and interventions with thanks given and no concerns noted. Verbalized understanding.
A progress note dated 04/16/2025 at 6:49 p.m. revealed Resident #10 was sent to ER last night for fall. That was her 3rd fall in two weeks. Resident was returned back with a sprained right ankle. Resident has been very confused and called 911 herself demanding to go to ER.
Review of the EMR revealed no Change in Condition/SBAR documented for transfer to hospital on 04/16/2025. There was no documentation to indicate the doctor was notified.
Review of the progress notes showed the following:
On 04/16/2025 at 7:25 p.m. the nurse called family and left message to call back to notify of resident going out to the hospital.
On 04/17/2025 at 12:24 a.m. facility called hospital for an update. Resident was admitted for encephalopathy.
On 04/22/2025 at 10:45 p.m. Resident readmitted from hospital via stretcher. Spoke with family, notified of arrival. Notified doctor of return. Gave orders to continue with hospital discharge orders and labs.
On 04/22/2025, Fall Risk Evaluation, score of 11.0.
On 04/25/2025 at 2:13 p.m. Change in Condition/SBAR for fall showed blood pressure 127/77 on 04/25/205 at 10:94 a.m.; pulse 79 at 04/25/205 at 10:94 a.m.; respirations 18 on 04/25/2025 at 10:04 a.m. All other areas blank.
A progress note dated 04/25/2025 at 2:16 p.m. showed during routine round this resident (#10) was found sitting on the floor next to her wheelchair, apparently reaching for an object. Resident stated, I was trying to reach for my dentures. Resident also stated, I did not hit my head. No injuries noted during assessment. Will continue to monitor. No distress noted. All parties were notified.
Review of a Change in Condition / SBAR for a fall on 04/26/2025 at 4:55 p.m. revealed Resident #10 was found sitting on the floor. Blood pressure 108/75 on 04/26/2025 at 6:51 p.m., pulse 97 04/26/2025 at 6:51 p. m. respirations 18 04/26/2025 at 6:51 p.m. Range of motion within normal limits. No blood. No complaint of pain. She stated that she was trying to reach the garbage can. She did not use the call light. Sitting back on her chair at the nursing station for safety. Started neuro checks. She was alert but confused. Doctor notified. Family notified. Primary Care Provider responded with the following feedback: none.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 55 105733 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105733 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689 On 04/26/2025 at 10;59 p.m. Fall Risk Evaluation was performed with a score of 13.0 meaning the resident was at risk for falls. Level of Harm - Minimal harm or potential for actual harm On 04/27/2025, 2:05 p.m. Change in Condition/ SBAR for fall revealed . Nursing observations, evaluation, and recommendations are Resident was found sitting on the floor in sitting position. Range of Motion within Residents Affected - Some normal limits. No blood. No complaint of pain. She stated that her foot got caught in wheelchair. She did not use the call light. She was sitting back in her chair at the nursing station for safety. Start neuro checks. She was alert but confused. Doctor notified. Family notified. Primary Care Provider responded with the following feedback: none.
A Change in Condition/SBAR and progress note for fall dated 05/03/2025 at 5:40 p.m. showed the Resident was found sitting on the floor. Range of motion was within normal limits. No bruises, no blood. Resident denies any pain. Doctor notified. Family notified. Primary Care Provider responded with the following feedback: Range of Motion within normal limits, start neurological checks.
On 05/03/2025 Fall Risk Evaluation was performed with a score of 15 meaning the resident was at risk for falls.
An IDT progress note dated 5/052025 at 12:29 p.m. showed Resident #10 was discussed with IDT team post fall. Resident noted to have been brought back to nurse's stations moments prior to fall per weekend supervisor. Noted slightly soiled. Care plan reviewed and updated for staff to offer resident toileting prior to leaving dining room in dining room bathroom. Family made aware of care plan change day of event. Referral to therapy placed.
Review of a Therapy Screen for change in condition dated 05/062025 at 9:11 a.m., showed initiated Therapy, please review and address screen. Referral to therapy completed.
Review of Neurological checks provided for 04/08/2025, 04/09, 04/10, 04/11, 04/12, 04/13, 04/26, 04/27, 04/28, and 04/29/2025 revealed Neuro check assessments were conducted on these dates. The review showed Neurological checks were not documented on 04/02, 04/03, 04/04, 04/25,05/03, 05/04/2025 and on 05/05/2025.
Review of the care plans showed Resident #10 was at risk for fall related to unsteady gait and weakness as of 04/02/205. Interventions included but not limited to resident education regarding call light usage and asking for assistance with ambulation, transfers, toileting etc. as of 04/11/2025. Bilateral floor mats while in bed as of 04/22/2025. Encourage appropriate foot wear as of 04/02/2025. Ensure trash can is within residents reach at bedside prior to leaving room. Staff to also offer to throw away any excess trash/clutter prior to leaving the room post patient care as of 04/28/2025. Low bed while in bed as of 04/22/2025. Palm Program as of 04/09/2025. Place items used in easy reach i.e. water, telephone, call lights as of 04/02/2025. PT and OT to screen prn as of 04/02/2025. Every 15-minute checks due to fall risk Ensure observation log is completed and returned to management as of 04/27/2025. Staff to offer resident assistance with denture application. If resident refuses, ensure that dentures are within reach as of 04/25/2025. Staff to offer resident usage of dining room bathroom prior to leaving lunch and dinner as of 05/05/2025. Staff to offer toileting assistance upon rising, before and after meals and every night as of 04/22/2025.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 55 105733 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105733 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689 During an interview on 05/14/2025 at 4:08 p.m. Staff B, LPN, UM stated the resident has had multiple falls.
She was very impulsive. Staff B stated psych was working with the resident regarding medications. Staff B, Level of Harm - Minimal harm or LPN stated they had increased her medications. Staff B stated Resident #10's last fall was on 05/03/202 and potential for actual harm they updated her care plans with interventions.
Residents Affected - Some During an interview on 05/15/2025 at 9:17 a.m. Director of Quality Assurance / Risk Manager (RM), The RM stated when a resident falls the nurses fill out a change in Condition / SBAR which includes a description of
the fall and the assessment. The RM stated for Resident #93 they documented in the facility forms but that was not part of the medical record. The RM stated the nurse was to pass the neurological form during nurse to nurse and then it was to go to the UM and then to her or medical records clerk for scanning in the medical record. The RM stated for all unwitnessed falls a neurological check was to be performed. The RM stated
they had initiated QAPI (Quality Assurance and Performance Improvement) on falls. The RM stated they have discovered the nurses are not documenting the falls in the medical record and are not performing the neurological checks. The RM stated the QAPI was only for preventing falls it did not include the documentation of the falls. The RM stated the possible negative outcome for not performing neurological checks was an injury to the brain or a subdural hematoma. The RM stated if the resident goes to the hospital
they still have to do neurological checks when they get back, if the hospital did not perform a CT scan on the resident. The RM stated they were not required to do a progress note if they describe the fall in the Change
in Condition/SBAR. The RM stated they have to document current vital signs on the Change in Condition / SBAR. The RM verified Resident #10 did not have neurological checks on the chart for the 04/16/2025, 04/25/2025, 05/03/2025 falls. The RM verified the 04/16/2025 SBAR for Resident #10 did not have accurate vital signs documented, they were from hours after the fall. The RM verified there was no documentation regarding the fall for Resident #11 on 04/18/2025, 04/20/2025 nor 05/08/2025. The RM stated the fall document for Resident #11 was in the facility forms only. The RM stated there was no documentation regarding the description of the fall, the assessment, which should include recent vital signs, skin impairments for Resident #11. The RM verified there were no neurological checks for Resident #93 for the fall on 05/12/2025.
During an interview on 05/15/2025 at 11:20 a.m. the Director of Nursing (DON) stated the falls should be documented post and should include any pain, range of motion, current vital signs, (specific to the fall), and note if any skin tears. The DON stated the neurological checks were to be done for all unwitnessed falls. The DON stated they were to be done for 72 hours. The DON stated the nurses do neurological checks on paper.
The DON stated the neurological form was kept at the desk. The DON stated the form was to be given to the RM. The DON stated the fall was to be documented in initially into the facility form and then the nurse should be filling out the Change in Condition/SBAR and should include most of the information about the fall. The DON stated the IDT met every morning, Monday through Friday and the supervisors monitor on weekends.
The DON stated the care plans are to be updated after the fall. The DON stated the care plans are reviewed once the team gets together for any needed adjustments.
Review of a facility policy titled Nursing/Risk Management - Risk Evaluation for Falls, revised July 2017, revealed a purpose to identify and address risk factors associated with resident falls, to determine the need for any special care, assistive device or equipment needs, assist with resident care planning needs and to confirm the continued accuracy of the evaluation.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 55 105733 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105733 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689 Post Fall - 1. Post fall a team meeting of all available should occur. The goal is to huddle, discuss and assess the area of the fall and surroundings prior to the end of shift. This meeting initiates the investigation Level of Harm - Minimal harm or process. The team should be comprised of the fall ambassador or therapist on duty that shift, nursing team potential for actual harm members and housekeeping. The post fall evaluation should be completed by the nurse 2. Therapy should screen for every post fall event 3. Interdisciplinary team (IDT) note will be utilized for documentation of repeat Residents Affected - Some fall review and new fall related interventions.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 55 105733 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105733 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services.
Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 34768 potential for actual harm Based on observation, interview and record review the facility failed to ensure medications were Residents Affected - Few administered prior to dialysis appointments for one (#93) of one sampled resident.
Findings included:
On 05/14/2025 at 8:41 a.m. Resident #93 was observed sitting at her bedside. She was not eating her breakfast. She stated, not good to greetings, turned her back and would not engage in conversation.
Resident #93 was admitted on [DATE REDACTED] and readmitted on [DATE REDACTED]. Review of the Admission Record showed diagnoses included but not limited to pneumonia, End Stage Renal Disease (ESRD), gastrostomy, adult failure to thrive, diabetes, dependent on renal dialysis, muscle weakness, difficulty in walking, anemia, Cerebrovascular Accident (CVA), hypertension, cardiac pacemaker, depression, atrial fibrillation, generalized anxiety disorder. Review of the admission, Minimum Data Set (MDS) dated [DATE REDACTED] showed Brief Interview for Mental Status (BIMS) score of 15 or cognitively intact. Section GG, Functional Abilities showed resident required partial to moderate assistance with toileting and showering. Section O, Special Treatments, Procedures, and Programs showed resident was on dialysis.
Review of current physician orders for Resident #93 showed orders for dialysis on Monday, Wednesday and Friday.
Amlodipine besylate 5 mg give 2 tablets in the morning for hypertension [HTN]
ASA [Aspirin] 81 mg [milligrams] in the morning for coronary artery disease [CAD]
Candesartan Cilexetil 32 MG [milligrams] Give 1 tablet by mouth in the morning for HTN
Labetalol HCl 100 MG Give 3 tablet by mouth 3 times a day for HTN
Review of the Medication Administration Record (MAR) for April 2025 showed:
Amlodipine besylate 5 mg give 2 tablets in the morning for HTN was not given on 4/18, 4/21, 4/23, and 4/28/25 in the a.m. (morning), due to absent from center.
ASA 81 mg in the morning for CAD was not given on 4/18, 4/21, 4/23, and 4/28/25, in the a.m., due to absent from center.
Candesartan Cilexetil 32 MG Give 1 tablet by mouth in the morning for HTN was not given on 4/18, 4/21, 4/23, and 4/28/25 in the a.m. due to absent from center.
Labetalol HCl 100 MG Give 3 tablet by mouth 3 times a day for HTN, was not given 4/18, 4/21, 4/23, 4/28, and 4/30/25 in the afternoon, due to absent from center.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 55 105733 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105733 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0698 Augmentin 500-125 mg twice a day for pneumonia for 3 days as of 4/17/25, was not given on 4/19/25 in the a.m., due to absent from center. Level of Harm - Minimal harm or potential for actual harm Ciprofloxacin HCL 500 mg twice a day for pneumonia for three days as of 04/16/2025, was not given on 4/19/25 in the a.m. due to absent from center. Residents Affected - Few
Review of the Medication Administration Record (MAR) for May 2025 showed:
Amlodipine besylate 5 mg give 2 tablets in the morning for HTN was not given on 05/02, 05/05, 05/07, and 05/12/25 in the a.m. due to absent from center.
ASA 81 mg in the morning for CAD was not given on 05/02, 05/05, 05/07, and 05/12/25, in the a.m., due to absent from center.
Candesartan Cilexetil 32 MG Give 1 tablet by mouth in the morning for HTN was not given on 05/02, 05/05, 05/07, and 05/12/25, in the a.m. due to absent from center.
Labetalol HCl 100 MG Give 3 tablet by mouth 3 times a day for HTN, was not given 05/02, 05/05, 05/07, 05/09, and 05/12/25 in the afternoon, due to absent from center.
Review of the progress notes for resident #93 revealed On 05/14/25 at 9:47 a.m. (during survey), this writer spoke with the dialysis center which communicated it was recommended for blood pressure medication to be administer 3-4 hours before dialysis.
Review of the care plans showed the resident had potential for complications related to dialysis for ESRD and required dialysis as of 04/16/2025. Interventions included but not limited to administer and monitor effectiveness of medications as ordered as of 04/16/2025; Communicate with dialysis center regarding medication, diet, and lab results as of 04/16/2025. Coordinate resident's care in collaboration with dialysis center as of 04/16/2025.
Resident was antiplatelet therapy related to diagnosis of CAD as of 04/16/2025. Interventions included but not limited to administer medication as ordered as of 04/16/2025.
During an interview on 05/14/2025 at 3:54 p.m. Staff A, Registered Nurse (RN) stated Resident #93 went to dialysis in the a.m., around 10 a.m. Staff A stated that if a resident misses their medication, they are to inform the medical provider for missed medications.
During an interview on 05/14/2025 at 4:08 p.m. Staff B, Licensed Practical Nurse Unit Manager (LPN, UM) stated Resident #93 goes out to dialysis around 9:40 a.m. Staff B stated the nurse should let the doctor know right away about any medications not taken. Staff B stated they discussed today about changing the time of
the medications for Resident #93. Staff B stated the nurse was talking to the dialysis center and the doctor about her medications and moving the medication times. Staff B, LPN, UM verified Resident #93 had not been getting her morning medications prior to dialysis. Staff B stated there was no reason why Resident #93 was not getting her medications before she left because she does not leave until 9:40 a.m. Staff B stated the nurses should have discussed with the doctor before today about the resident not getting her morning medication.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 55 105733 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105733 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0698 During an interview on 05/15/2025 at 11:20 a.m. the Director of Nursing (DON) stated residents were to receive the medications as ordered by the doctor. The DON stated the nurse should be calling the doctor Level of Harm - Minimal harm or about not giving medications, for any reason. The DON stated the nurse should find out what the doctor potential for actual harm would like the nurse to do. The DON verified there was no documentation regarding the medications not given for Resident #93. The DON reviewed the progress notes for Resident #93 and found no documentation Residents Affected - Few regarding notifying the doctor of missing medications. The DON verified there was only documentation showing she was on a LOA (Leave of Absence). The DON stated she would expect to see the doctor notified. The DON stated there was a window for medication administration times in the morning. The DON stated she was not sure why Resident #93 did not get the medications before she left for dialysis. The DON stated it would depend on what the doctor said if the nurses were to give the medications before dialysis or not. The DON stated that the issue of medications not administered before dialysis had not come up before.
Review of the facility's policy, Medication Administration, dated 07/2023 showed to administer the following according to the principles of medication administration, including the right medication, to the right guest / resident at the right time, and in the right dose and route. Procedure 1. Verify physician's orders for medications to be administered. 10. Read the Medication Administration Record (MAR) for the ordered medication, dose, route, and time. Verify / clarify orders as needed prior to administration 13. Verify the following, again, by comparing medication to MAR prior to administering: Correct guest / resident, correct medication, expiration date, dose and dosage form, route and time.
Review of the facility's policy, Change in a Resident's Condition or Status, dated October 2014 showed the facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status. Procedure: 1. The Nurse Supervisor / Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been among others, a reaction to medication and / or medication error, a need to alter the resident's medical treatment significantly and refusal of treatment, medications or meals (i.e. two (2) or more consecutive times).
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 55 105733 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105733 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0699 Provide care or services that was trauma informed and/or culturally competent.
Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49227 potential for actual harm Based on interviews and record reviews the facility failed to ensure two residents (#81 and #33) out of three Residents Affected - Some reviewed for mood and behavior received culturally competent trauma-informed care related to identifying triggers that may cause re-traumatization.
Findings included:
1.
During an interview on 5/13/25 at 1:44 P.M. Resident #81 stated loud noises were a trigger for him and he completes self-calming exercises. The resident stated when he felt anxious he would go to a quiet place.
A review of Resident #81's admission record showed an admitted [DATE REDACTED] with diagnoses to include bipolar disorder and Post Traumatic Stress Disorder (PTSD).
A review of Resident's # 81's Medication Administration Record (MAR), dated May 2025, showed orders for Bupropion twice daily for depression, Lamotrigine twice daily for mood.
A review of Resident #81's Trauma Informed Care Questionnaire (TICQ) dated 4/17/25, showed the resident had served in a war zone, thought his life was in danger and was seriously injured.
A review of care plan showed Resident #81 initiated on 4/17/25 showed the resident has a significant trauma exposure related to history of prior service in war zone/exposure to war-related casualties and history of a serious car accident. The goal showed Resident # 81 will state feeling safe in the facility environment through the next review date, revised on 4/30/25. The interventions included: address resident in a calm, quiet and respectful manner, offer resident information and encourage active participation in the development of the resident care plan, psychiatry, and psychological services consultation will be requested as needed and staff will attempt to ensure a consistent and predictable routine for resident care and minimize unexpected changes.
A review of Resident #81's admission Minimum Data Set (MDS) dated [DATE REDACTED], showed Section C, cognitive patterns Brief Interview for Mental Status Score (BIMS) of 15, indicating intact cognation. Review of section D, mood - showed feeling down, depressed, or hopeless occurred 2 to 6 days.
A review of Resident# 81's psychological evaluation dated 5/8/25 showed the resident's emotional functioning is sufficient to alter his baseline functioning and therefore, treatment is medically necessary. The resident may benefit from individual therapy to help reduce symptoms of depression.
A review of Resident #81's visual/bedside Kardex (a document used by staff with care instructions specific to each resident) Report as of 5/15/25, sections related to safety, monitor, resident care, did not include trauma related care interventions.
During an interview on 5/14/25 at 8:05 A.M. Staff M, Registered Nurse (RN) assigned to Resident #81 said
she did not know if any of her residents had a PTSD diagnosis.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 55 105733 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105733 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0699 During an interview on 5/14/25 at 2:35 P.M. with the Social Services Director (SSD) and the Social Service Assistant (SSA), the SSD said she completed Resident #81's TICQ on admission and does not recall what Level of Harm - Minimal harm or was on the form. The SSD stated the care plan including the interventions are initiated based on the potential for actual harm residents' response to the questions.
Residents Affected - Some During an interview on 5/15/25 at 8:50 A.M. with Resident #81 and the SSD. Resident #81 said when he woke up in the mornings his anxiety level is at a 5. The SSD said, he does not have any triggers.
The review of the care plan dated 4/17/25 and interview with SSD revealed Resident #81 was not assessed or care planned for triggers or retraumatization.
48223
2.
During an interview and observation on 05/12/25 at 09:53 AM, Resident #33 was teary eyed and emotionally upset as she discussed her prior nursing home experience. Resident #33 stated she was abused and treated badly at the previous nursing home. Resident #33 stated since being admitted to the facility no one had discussed the diagnosis of PTSD or any triggers that would cause her re-traumatization. Resident #33 stated being seen by psychology/psychiatrist at the facility.
Review of the Admission Record showed Resident #33 was admitted to the facility on [DATE REDACTED] with diagnoses that included but not limited to Generalized Anxiety Disorder, and Major Depressive Disorder, and other comorbidities.
Review of Resident #33's Minimum Data Set (MDS) most recent quarterly assessment dated [DATE REDACTED] revealed resident was cognitively intact, with a Brief Interview for Mental Status (BIMS) score of 15/15.
Review of Resident #33's Psychiatric Nurse Practitioner note dated 2/27/2025 revealed: Follow-up visit at SNF. A new problem has emerged Resident #33 made an allegation of abuse towards a staff member. She states that the staff member punched her multiple times in the head while adjusting the [total lift]. Resident #33 states the staff member did apologize to her after the incident. Resident #33 states she has had to use
the [total lift] for over a year and had never had an incident with anyone like this while using the lift. The resident states the pain was enough that she asked for a pain pill after it happened. She is feeling better today but is scared to be in the care of that particular staff member otherwise resident is feeling safe in facility. Resident #33 has history of trauma in her previous facility and had another incident with staff member
in this facility a few weeks ago. She is tearful when discussing these incidents.
Review of Resident #33's Psychiatric Nurse Practitioner note dated 2/7/2025 revealed: Staff reported Resident #33 was recently harassed by another staff member that is currently being investigated. Resident #33 states a CNA (Certified Nursing Assistant) was very rough ., was harsh while providing care, and made Resident #33 feels scared while being provided personal care. Resident #33 reports that the same CNA was also very rude saying things like why are you wearing a wig you know you aren't going anywhere. Resident #33 so states that at a previous SNF (Skilled Nursing Facility) was horrible and she was abused while there. Resident #33 is anxious that the same thing will happen here.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 55 105733 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105733 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0699 Review of Resident #33's Trauma Informed Care Questionnaire (TICQ) dated 3/3/25, 2/12/25, and 2/5/25 revealed all answers to the trauma questionnaire was documented as no. Level of Harm - Minimal harm or potential for actual harm Review of Resident #33's record did not reveal a Brief Trauma Questionnaire (BTQ) or TICQ dated 3/5/2025 or after. Residents Affected - Some
Review of Resident #33's care plan showed a focus area dated 3/5/2025, Resident has a history of significant trauma exposure related to - reported history of abuse at prior nursing facility. The goal showed Resident #33 will state feeling of safety in the facility environment through the next review date. The interventions all dated 3/5/2025 showed psychiatry consult will be requested as needed, psychology services consult will be requested as needed, social services staff will complete the Brief Trauma Questionnaire (BTQ) with the resident. There were no triggers identified in the care plan.
During an interview on 05/14/25 at 3:15 PM, Staff D, Certified Nursing Assistant (CNA) stated not being aware of any Residents in the facility with the diagnosis of PTSD or with a history of trauma.
During an interview on 05/14/25 at 3:18 PM, Staff H, CNA stated being aware Resident #33 had a bad experience prior to this facility. Staff H, CNA stated did not know if Resident had any triggers.
During an interview on 05/14/25 at 5:47 PM, Staff I, Licensed Practical Nurse (LPN) stated not being aware of Resident #33's past experiences or if any triggers were known.
During an interview on 05/15/25 at 09:10 AM, Staff E, CNA stated being aware of Resident #33 had something but doesn't know exactly what and is not aware of any triggers.
During an interview on 05/15/25 at 09:23 AM, Staff F, LPN stated being aware of Resident #33 past experience from speaking with resident. Staff F, LPN stated not being aware of any triggers.
During an interview on 05/15/25 at 10:21 AM, Social Services Director (SSD) stated Resident #33 trauma evaluations were all with 'no' responses after the allegations. The SSD stated if during the questionnaire a 'yes' response was given, then we would discuss the event in detail and develop a care plan with triggers.
During an interview on 05/15/25 at 11:53 AM the Director of Nursing (DON) stated the facility should try to identify triggers, if they could. The DON stated the care plan interventions will then flow over to the plan of care documentation the CNAs can view.
Review of an undated facility policy titled Person-centered Comprehensive Care Plan revealed under guideline: It is the practice of the center to develop and implement a person-centered comprehensive care plan that includes measurable objectives and timeframes to meet their preferences and goals, and address
the guest/resident's nursing, medical, physical, mental, and psychosocial needs. The comprehensive person-centered care plan will be developed based on the Minimum Data Set (MDS) to assess the guest/resident's clinical condition, cognitive and functional status, and use of services. The comprehensive care plan will address the following: . Trauma-informed Care, Interventions, and Potential Triggers.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 55 105733 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105733 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0759 Ensure medication error rates are not 5 percent or greater.
Level of Harm - Minimal harm or 49227 potential for actual harm Based on observations, record reviews, and interviews, the facility failed to ensure the medication error rate Residents Affected - Few was less than 5%. Thirty-three medication opportunities were observed, and two errors were identified for Resident #1 resulting in an error rate of 6.06%
Findings included:
On 5/14/25 at 8:23 A.M. Staff M, Registered Nurse (RN) was observed administering medication to Resident #1. Prior to the medication administration, Staff M, RN obtained the following vital signs: pulse 95 and blood pressure 115/83. Staff M, RN administered the following medications:
-Vitamin D 1000 Units
-Tizanidine 2mg, 3 tablets
-Oxycodone 10 mg
-Methimazole 5 mg
-Midodrine HCl 5 mg
-Aspirin low dose 81 mg
-Omeprazole 20 mg, 2 capsules
-Quetiapine 400 mg
-Duloxetine HCl 60 mg, 2 capsules
-Bupropion SR 100 mg
-Pregabalin 150 mg
Following the medication administration observation, a review of the physician's orders for Resident #1 revealed Aspirin 325 MG Give 1 tablet by mouth in the morning for anticoagulant and Midodrine HCl 5 mg Give 1 tablet by mouth three times a day for hypotension hold for systolic blood pressure greater than 110.
During an interview on 5/14/25 at 12:50 PM, Staff M, RN said, after administering Aspirin 81mg to Resident #1 she realized the wrong dose was given and the Midodrine 5 MG should not have been administered.
During an interview on 5/14/25 at 12:50 PM with the Director of Nursing (DON) said nurses are expected to administer medications as ordered.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 55 105733 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105733 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0759 Review of the facility's policy titled, General Dose Preparation and Medication, revised on 11/15/24 showed
the following: Applicability procedures relating to general dose preparation and medication administration. Level of Harm - Minimal harm or Procedure: .Only prepare medications for one resident at a time, using a 3-way-check (i.e., comparing the potential for actual harm medication to the MAR [Medication Administration Record] and to the prescription label) .Prior to administration of medication, facility staff should take all measures required by facility policy and applicable Residents Affected - Few law, including, but not limited to the following: Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident If necessary, obtain vital signs During medication administration, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: . Facility staff should verify that the medication name and dose are correct when compared to the medication order on
the medication administration record.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 55 105733 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105733 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food
in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 50570
Residents Affected - Many Based on observations and interviews, the facility did not ensure food safety standards were followed, in the kitchen and two of two nourishment rooms, as evidenced by improper infection control practices including hand hygiene, ice buildup in the walk-in freezer, the dish machine and dumpster areas not maintained in a clean sanitary condition, and resident food items were not labeled/dated.
Findings included:
On 5/12/25 at 9:28 a.m., an initial tour of the kitchen was conducted. An interview and observation of Staff Q, Culinary Assistant was conducted while he was utilizing the dish machine. An observation of the top of the dish machine revealed a plastic water bottle. An observation of Staff Q, Culinary Assistant revealed he grabbed the plastic water bottle, drank from it, and placed it back on top of the dish machine. He said he was thirsty as the dish machine area was hot. Observations of the interior and bottom edges of the dish machine hood revealed multiple areas of brown and red discoloration. Further observation of the dish machine area revealed a white rag with light yellow-colored stains, on the top shelf of a utility rack, with clean kitchen items.
The rag was in close proximity to clean items intended to hold beverages. Further observations of the dish machine area revealed Staff R, Culinary Assistant touched the rim of the garbage can, then went to the rack with clean items to retrieve kitchenware. An observation of Staff R, Culinary Assistant revealed he moved on to another task and did not perform hand hygiene after touching the garbage can.
On 5/12/25 at 9:43 a.m. an observation of the walk-in freezer revealed a box of plant-based chicken tenders with ice buildup, approximately 3-4 inches in height on top of the food item.
On 5/12/25 at 10:03 a.m. an observation of the dumpster revealed the right-side door was open. An interview with the Certified Dietary Manager (CDM) revealed all staff are responsible for cleanliness and closing the doors of the dumpster, but it mainly falls on the kitchen staff and maintenance.
On 5/12/25 at 10:08 a.m. an observation of the refrigerator in the nourishment room, on the a-wing, revealed
a carton of Ensure clear and two 32-ounce tubs of yogurt that were not labeled with a resident's information.
He said the Ensure clear is not a nutritional supplement the facility provides, as he is the one who orders them. Further observation of the freezer in the a-wing nourishment room revealed a, Hot Pocket, with no resident information, as well as no date of expiration or when the original packaging was opened.
On 5/12/25 at 10:17 a.m., an observation of the refrigerator in the nourishment room, on the c-wing, revealed
a large bottle of juice that was not labeled with a resident's information. The CDM said he toured the nourishment rooms every morning, to include labeling and dating of items in the refrigerators and freezers.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 55 105733 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105733 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812 On 5/14/25 at 11:41 a.m., an observation was conducted of the lunch meal tray line in the kitchen. An
observation of Staff T, Culinary Assistant revealed she was washing her hands with water without soap in the Level of Harm - Minimal harm or hand washing sink. She said she was allergic to soap and usually uses hot water to wash her hands. She potential for actual harm said she could use sanitizer instead of soap and pointed to the 3-compartment sink and stated, There's sanitizer there. She was observed going to the area with the 3-compartment sink. An interview with Staff T, Residents Affected - Many Culinary Assistant revealed she used the sanitizing solution in the 3-compartment sink to wash her hands.
She said there wasn't a gel hand sanitizer available but thinks that it would be okay to use. At 11:44 a.m., an
observation of Staff T, Culinary Assistant revealed she was on the tray line and scratched her neck, touched her glasses and was leaning over clean trays and the bottom part of insulated lids. Staff T, Culinary Assistant did not wash her hands.
On 5/14/25 at 11:54 a.m Staff S, [NAME] was observed in the kitchen tray line plating food for the lunch meal service. She started plating food without conducting hand hygiene prior to this task. Staff S, [NAME] was observed touching the beverage and dessert cart in between plating the resident's food. At 11:56 a.m., an
observation of Staff S, [NAME] revealed she was touching her pockets. Hand hygiene was not observed between these tasks.
On 5/15/25 at 12:34 p.m., an interview with the CDM was conducted. He said the hood of dish machine has not been cleaned by kitchen staff and isn't part of their cleaning schedule. He stated, It might be under the maintenance cleaning schedule. The CDM stated the brown looking substance on the surface was rust, and confirmed it is not a cleanable surface. The CDM said maintenance completed a monthly inspection of the dish machine which included a, Touch up, cleaning of the hood. The CDM said staff are not supposed to have personal items or beverages while they are utilizing the dish machine. The CDM said the expectation was for staff not to have personal food or drinks in the kitchen area. He said there was a refrigerator in his office for personal items. He said in February 2025 staff were provided an in-service about cross contamination in work areas. The CDM said staff should be performing hand hygiene before starting new tasks. He said staff should be washing their hands after touching their face, hair, or any part of their body while handling food. The CDM said if staff are touching garbage cans, dirty dishes, or anything potentially soiled, they should be washing their hands. The CDM said he was not aware of a dietary staff member that could not use soap. He said all of this kitchen staff, including Staff T, Culinary Assistant, performed hand hygiene with soap during the demonstration in-services. He stated he would not expect dietary staff to wash their hands with the sanitizing solution in the 3-compartment sink. He stated, It would be potential cross contamination and an infection control issue. He stated, I'm not sure if that soap is approved for hand washing. The CDM said dumpster doors should be closed at all times to prevent pests and rodents. He stated, All departments have access to it and should be aware of closing the doors. He said he reviewed the nourishment rooms at least once or twice a day. The CDM confirmed resident items need to be labeled with their name and room number on them. The CDM said in orientation staff are educated about labeling and dating items in the nourishment refrigerators and freezers.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 55 105733 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105733 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812 A review of the facility's policy titled Handwashing - Culinary and Glove Use, dated 4/15/24, revealed the following, Purpose: Handwashing is necessary to prevent the spread of bacteria that may cause foodborne Level of Harm - Minimal harm or illnesses. Culinary team members shall clean their hands in a handwashing sink or approved automatic hand potential for actual harm washing center and may not clean hands in a sink used for food preparation, ware washing, or in a service sink used for the disposal of mop water or similar waste. Further review of the policy revealed the following, . Residents Affected - Many 6. Frequency of Handwashing: a. Culinary team members shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single service and single use articles and also in the following situations: . ii. After hands have touched anything unsanitary i.e., garbage, soiled utensils/equipment, dirty dishes, etc. iii. Hands have touched bare human body parts other than clean hands (such as face, nose, hair etc.). iv. After coughing, sneezing, or blowing your nose, using tobacco, eating or drinking.x. After engaging
in any activity that may contaminate the hands.
A review of the facility's policy titled 3 Compartment Sink- Manual Warewashing Policy, dated 4/15/24, revealed the following under policy and compliance guidelines, . Warewashing sinks may not be used for handwashing.
A review of the facility's policy titled Nourishment and Life Enrichment Refrigerator and Freezer Store, dated 11/1/24, revealed the following, Purpose: It is the right of the Residents/Guests of the center to have food brought in by family or other visitors, however, the food must be handled in a way to ensure the safety of the Resident/Guest. Further review of the policy revealed the following:
-Guidelines: 1. Foods in the nourishment and life enrichment refrigerators can be kept for up to 3 days or per manufacturer guidelines (see #4 and# 7 for further information). Freezer foods once opened can be kept up to 90 days (3 months). 3. All food items that are prepared by the family members or visitors must be stored in
the following manner: a Stored in an airtight container or Ziploc bag b. Labeled with the Resident/Guest name and room number c. Labeled with date of storage. 4. All food items that are pre-packed and sealed from the manufacturer must be labeled with Resident/Guest name and room number. These items will be held until the manufacturer's expiration date. A. After the manufacturer sealed food item is opened it may be resealed, labeled, dated and held for 3 days. b. Freezer foods after opening may be sealed, labeled, dated and held for 90 days. 5. Foods that are not easily identifiable without removing a cover, such as a bowl of applesauce with a lid with a lid; must also be labeled with content.
A review of the facility's policy titled Resident personal food, dated 10/2024, revealed the following, Policy: All residents have the right for family members and visitors to provide preferred or requested foods and fluids from outside of the facility, except where the health and safety of the individual or other residents would be endangered. Items brought into the facility will be stored under sanitary conditions. Further review of the policy revealed the following, Procedure . 2. Labeled and dated perishable items may be stored under refrigeration in the nursing unit consistent with standards of food storage.
(Photographic Evidence Obtained)
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 55 105733 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105733 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880 Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49227 potential for actual harm Based on observations interviews, and policy reviews the facility failed to ensure, 1. Respiratory equipment Residents Affected - Many and supplies were dated and stored in a sanitary manner in seven rooms (134, 133, 143, 137,113, 120 and 126) of 65 rooms toured, and did not ensure Hand Hygiene was performed during two medication administration observations and 3. failed to ensure hand hygiene was performed during dining and kitchen tours during two (5/12/25 and 5/14/25) of four days of survey and 4. did not ensure clean linen was handled
in a manner to prevent cross contamination during one of one laundry facility tours.
Findings Included:
1.
During a tour on 5/12/25 at 9:29 A.M. in room [ROOM NUMBER], a nebulizer mask was observed uncovered laying in the top drawer of the resident's bedside table and the in use nasal canula was not dated.
During a tour on 5/13/25 at 9:43 A.M. in room [ROOM NUMBER], a nebulizer treatment mask was observed lying on top of a see through a plastic bag.
During a tour on 5/13/25 at approximately 10:00 A.M. in room [ROOM NUMBER], a Continuous Positive Airway Pressure (CPAP) mask was observed lying uncovered on top of the bedside table with a back scratcher lying on top. An uncovered nebulizer mask was placed on the countertop located near the foot of
the bed.
During a tour on 5/13/25 at 9:58 A.M. in room [ROOM NUMBER] an uncovered CPAP mask was observed lying on top of the bedside table and the opening to the mask was exposed. The prefilled bubble humidifier plastic bottle was placed directly on the floor. (Photographic evidence obtained)
During an interview on 5/14/25 at 2:30 P.M. Staff B, Licensed Practical Nurse (LPN) , Unit Manager (UM) said the nebulizer mask should be rinsed after each use, dried and placed in a bag. Staff B stated each week
a vendor changes and labels oxygen supplies. She said nasal canula's should be labeled with the date it was changed. Staff B, LPN, UM said staff are expected to date oxygen supplies.
During a review of a facility grievance form, dated 5/8/25 showed an unidentified resident's family member reported nebulizer masks uncovered.
During breakfast and lunch observations on 5/12/24 and 5/13/24, Staff J, Certified Nursing Assistant (CNA) delivered trays to residents on Unit C and did not offer hand hygiene prior to or during delivery of the meal trays.
During an interview on 5/14/25 at 8:54 AM, Staff J, CNA said she always offer residents hand hygiene with meal tray delivery. She did not say why she did not offer hand hygiene during these encounters.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 55 105733 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105733 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880 During medication administration observation on 5/14/25 at 8:05 A.M. on Unit C with Staff M, Registered Nurse (RN). Staff M, RN missed five opportunities for hand hygiene, prior to and after using the Level of Harm - Minimal harm or thermometer, a wrist blood pressure cuff and a finger pulse oximeter and placing the items on top of the potential for actual harm medication cart. Staff M, RN did not perform hand hygiene prior to administering medications, while holding a medication cup with medications for Resident #214, and prior to placing sugar packets from a different Residents Affected - Many resident on their bedside table. Staff M, RN did not perform hand hygiene before touching another resident's medication cup.
During an interview on 5/14/25 at 12:50 P.M Staff M, RN, confirmed she did not perform hand hygiene according to the facility policy during medication administration.
On 5/14/25 at 10:56 A.M. Medication administration observation was condcuted with Staff F, Licensed Practical Nurse (LPN). Staff F, LPN did not perform HH prior to entering and after leaving Resident #41's room. He placed gloves prior to obtaining finger stick blood glucose and removed gloves after the test was completed without performing hand hygiene. While wearing gloves Staff F, LPN cleaned and disinfected the glucometer machine without performing hand hygiene. Staff F, LPN prepped medications without gloves. Staff F, LPN then placed and removed gloves prior to administering insulin without performing hand hygiene. Staff F , LPN performed HH did not perform HH before and after glove use while obtaining blood glucose level, cleaning the glucometer and administering insulin.
During an interview on 5/14/25 at approximately 11:26 A.M Staff F, LPN confirmed he did not perform hand hygiene and stated, should have.
An interview was condcuted on 5/14/25 at 2:06 P.M. with Staff M, LPN, UM. Staff M, LPN,UM said, Staff should wash hands before and after leaving the room when all else fails wash your hands.
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2.
On 5/12/25 at 9:28 AM an interview and observation of Staff Q, Culinary Assistant was conducted as he was utilizing the dish machine. An observation of the top of the dish machine revealed a plastic water bottle. An
observation of Staff Q, Culinary Assistant revealed he grabbed the plastic water bottle, drank water from it, and placed it back on top of the dish machine. He said he was thirsty as the dish machine area was hot. Further observations of the dish machine area revealed Staff R, Culinary Assistant touched the rim of the garbage can, then went to the rack with clean items to retrieve kitchenware. An observation of Staff R, Culinary Assistant revealed he moved on to another task and did not perform hand hygiene after touching
the garbage can, (Photographic Evidence Obtained).
On 5/12/25 at 11:56 AM an observation of the dining room during the lunch meal was conducted. An
observation of the Human Resources (HR) Director revealed he was assisting with providing coffee to residents. He was not observed performing hand hygiene before providing the beverages. Further
observations of the HR Director revealed he provided coffee to one resident, then put a sugar substitute in another resident's cup and stirred the beverage. Observations of the HR Director revealed he touched the outside of the garbage can when throwing a food item away. Further observations of the HR Director, during
the lunch meal service in the dining room, revealed he touched the arm rests and handles of resident's wheelchairs, as well as his belt, face and eye. Throughout these observations hand hygiene was not observed.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 55 105733 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105733 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880 On 5/12/25 at 12:50 AM an observation of the Staffing Coordinator/Certified Nursing Assistant (CNA), in the dining room during the lunch meal, revealed he sat down next to a resident to assist with feeding. An Level of Harm - Minimal harm or observation of the Staffing Coordinator/CNA revealed he did not perform hand hygiene prior to assisting with potential for actual harm feeding the resident. He was observed touching the handle of the resident's wheelchair, their plate and assisting with providing them a beverage. Further observation of the Staffing Coordinator/CNA revealed he Residents Affected - Many touched and wiped his eyes, with the collar of his shirt, while assisting with feeding the resident.
On 5/14/25 at 11:41 AM an observation was conducted of the lunch meal tray line in the kitchen. An
observation of Staff T, Culinary Assistant revealed she was washing her hands with water in the hand washing sink. She said she was allergic to soap and usually uses hot water to wash her hands. She said she could use sanitizer instead of soap, pointed to the 3-compartment sink and stated, There's sanitizer there.
She was observed going to the area with the 3-compartment sink. An interview with Staff T, Culinary Assistant revealed she used the sanitizing solution in the 3-compartment sink to wash her hands. She said there wasn't a gel hand sanitizer available but thinks that it would be okay to use. At 11:44 a.m., an
observation of Staff T, Culinary Assistant revealed she was on the tray line and scratched her neck, touched her glasses and was leaning over clean trays and the bottom part of insulated lids.
On 5/14/25 at 11:54 AM an observation was conducted in the kitchen where Staff S, [NAME] was plating food for the lunch meal service. She started plating food without conducting hand hygiene prior to this task. Staff S, [NAME] was observed touching the beverage and dessert cart in between plating the resident's food. At 11:56 a.m., an observation of Staff S, [NAME] revealed she was touching her pockets. Hand hygiene was not observed between these tasks.
On 5/15/25 at 11:41 AM an interview with the Director of Nursing (DON) was conducted. She said staff are educated on using hand gel during the meal service. She said upon hire staff are educated on hand hygiene.
The DON stated, They are re-educated on hand hygiene all the time. She said staff should be performing hand hygiene between residents when serving meals. The DON said if staff are setting the tray down and not touching residents, they don't have to use hand gel. She said she conducts observations every day during dining and confirmed there are opportunities for improvement related to hand hygiene.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 55 105733 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105733 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880 On 5/15/25 at 1:04 AM an interview was conducted with the Certified Dietary Manager (CDM). He said staff are not supposed to have personal items or beverages while they are utilizing the dish machine. The CDM Level of Harm - Minimal harm or said the expectation is staff should not have personal food or drinks in the kitchen area. He said there is a potential for actual harm refrigerator in his office for personal items. He said in February 2025 staff were provided an in-service about cross contamination in working areas. He stated, They should be well versed in infection control because Residents Affected - Many they've completed quizzes and videos. He said his expectations for the dietary staff related to hand hygiene are the following, put their hair restraint first, wash their hands when they come in the kitchen, start one task, finish that task then remove the gloves, and wash their hands. The CDM said staff should be performing hand hygiene before starting new tasks. He said staff should be washing their hands after touching their face, hair, or any part of their body while handling food. The CDM said if staff are touching garbage cans, dirty dishes, or anything potentially soiled, they should be washing their hands. He stated wearing gloves is, Preferable if you're grabbing utensils, plates, anything that is going to the residents' mouth. The CDM said in February 2025 he provided an in-service/re-education to 13 kitchen staff about hand washing. He said he demonstrated, staff did a return demonstration, and he provided them a quiz to complete. The CDM said he is not aware of a dietary staff member that can't use soap. He said all of this kitchen staff, including Staff T, Culinary Assistant, performed hand hygiene with soap during the demonstration in-services. He said he would not expect dietary staff to wash their hands with the sanitizing solution in the 3-compartment sink. He stated, It would be potential cross contamination and an infection control issue. He stated, I'm not sure if that soap is approved for hand washing.
On 5/13/25 at 9:19 AM an observation was conducted in room [ROOM NUMBER]. A nebulizer mask and machine was observed on the seat of the resident's recliner. The mask and machine were not stored in a bag, (Photographic Evidence Obtained).
48223
3.
On 05/12/25 at 09:43 AM and 05/13/25 at 12:57 PM in room [ROOM NUMBER] bed by the window was observed with a nebulizer mask sitting on top of the nightstand unbagged next to the resident's bed.
On 05/12/25 at 10:15 AM in room [ROOM NUMBER] bed by the window was observed with a nebulizer mask sitting on top of the nightstand unbagged next to the resident's bed.
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4. On 05/15/2025 at 12:07 PM Staff U, Laundry Aide was observed placing clean laundry under his chin
during laundry folding. Staff U let a sheet touch the floor while he was folding. Staff U stated he should not place the laundry under his chin. He stated he was trying to remember not to do that. He stated he did that at home when he folded his personal laundry.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 55 105733 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105733 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880 During an interview on 05/15/2025 at 1:21 PM the Infection Control Preventionist (ICP) stated hand sanitizing was to be used between each resident contact. He stated hand sanitizing was to be performed between Level of Harm - Minimal harm or each resident they pass a tray to. ICP stated they encourage the residents to hand sanitize also. The ICP potential for actual harm stated the staff was to hand sanitize between each resident. The ICP stated the staff was to have their own hand sanitizer or use the machines on the wall. The ICP stated the staff had been educated regarding Residents Affected - Many cleaning of multi-use equipment such as blood pressure cuffs, thermometers, pulse oximeters. The ICP stated the expectation was to clean the equipment between resident use. The ICP stated he educated the staff yesterday (05/14/2025) on how to use the manual or tower blood pressure cuffs because the wrist blood pressure cuffs if the cuffs cannot be cleaned adequately. The ICP stated the nebulizer was to be stored in a plastic bag at the bedside when not in use. The ICP stated the oxygen tubing should be dated. The ICP stated the tubing was changed weekly by a respiratory company and they were to date the tubing when they changed it. He stated the tubing was good for 7 days. The ICP stated the nurse can change the tubing as needed also. The ICP stated he was not aware of anyone being allergic to soap. The ICP stated he should be made aware of anyone being allergic to soap so we can make accommodations. The ICP stated anyone allergic to soap can use hand sanitizer. The ICP stated he gave an in-service in the kitchen in March 2025 at
the sink, and no one stated they were allergic to soap. The ICP stated the kitchen manager should be watching his employees sanitizing their hands. The ICP stated it was not acceptable to put their hands into
the 3-in-1 sink for sanitizing their hands. The ICP stated the nurses should be hand sanitizing during medication pass. The hand sanitizing should occur before preparing medicines, once the medications are ready, and before entering the resident room and upon exiting the resident room
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 55 105733 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105733 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880 Review of the facility's policy titled Infection Prevention and Control Manual - Infection Surveillance - Overview dated December 2020 revealed: Purpose Infection prevention begins with routine and ongoing Level of Harm - Minimal harm or surveillance to identify possible communicable diseases or infections before they can spread to other potential for actual harm persons in the facility or have the potential to cause, an outbreak. This facility has established a system, based upon national standards of practice and the facility assessment to closely monitor all residents who Residents Affected - Many exhibit signs/symptoms of infection through ongoing surveillance including a systematic method for collecting, analyzing and interpretation of data, followed by dissemination of that information to identify infections, infection risks and outbreaks to those who can improve the outcomes for quality. The intent of surveillance is to identify possible communicable diseases or infections before they can spread to other persons in the facility. In addition, Surveillance is crucial in the identification of possible clusters, changes in prevalent organisms, or increases in the rate of infection promptly. The results should be used to plan infection control activities, direct in-service education, and identify individual resident problems in need of intervention. Two types of surveillance (process and outcome) implemented in healthcare facilities. I. Process Surveillance Process surveillance reviews practices directly related to resident care in order to identify whether the practices comply with facility infection prevention and control procedures and policies based on recognized guidelines. Examples of this type of surveillance include but are not limited to: *Monitoring of compliance with transmission-based precautions, * Proper hand hygiene, * The proper use and disposal of personal protective equipment, * Injection safety, * Point-of-care testing, * Urinary catheter care, * Wound care, * Invasive treatments, * Incontinent care, * Dialysis care, *Management of bloodborne pathogen exposure, * Cleaning and disinfection of products, equipment or environmental surfaces, * Handling, storing, processing and transporting linens according to procedure II. Outcome Surveillance The outcome surveillance process consists of collecting/documenting data on individual comparing the collected data to standard written definitions (criteria) ofinfections 1. The Infection Preventionist or other designated staff reviews data (including residents with fever or purulent drainage, and cultures or other diagnostic test results consistent with potential infections) to detect clusters and trends and to be able to identify and report evidence of a suspected or confirmed HAI or communicable disease. The facility's program should choose to either track the prevalence of infections (existing/current cases both old and new) at a specific point or focus
on regularly identifying new cases during defined time periods. When conducting outcome surveillance, the facility may choose to use one or more of the automated systems and authoritative resources that are available, and include definitions. Monitoring the implementation of the program, its effectiveness, the condition of any resident with an infection, and the resolution of the infection are considered an integral part of the healthcare facility surveillance. The healthcare facility monitors adherence to facility policies and procedures (e.g., dressing changes and transmission-based precaution procedures) to ensure consistent utilization of practice standards. Quality Assessment and Assurance Committee (QAA) 1. The designated IP or at least one of the individuals if there are more than one IP will regularly attend and report on the Infection Prevention and Control Program at the facility's quality assessment and assurance committee. 2. The responsibilities include active implementation and reporting on current Quality Assurance and Performance Improvement projects.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 55 105733 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105733 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880 A review of the facility's policy titled Handwashing - Culinary and Glove Use, dated April 15, 2024, revealed
the following, Purpose: Handwashing is necessary to prevent the spread of bacteria that may cause Level of Harm - Minimal harm or foodborne illnesses. Culinary team members shall clean their hands in a handwashing sink or approved potential for actual harm automatic hand washing center and may not clean hands in a sink used for food preparation, ware washing, or in a service sink used for the disposal of mop water or similar waste. Further review of the policy revealed Residents Affected - Many the following, . 6. Frequency of Handwashing: a. Culinary team members shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single service and single use articles and also
in the following situations: . ii. After hands have touched anything unsanitary i.e., garbage, soiled utensils/equipment, dirty dishes, etc. iii. Hands have touched bare human body parts other than clean hands (such as face, nose, hair etc.). iv. After coughing, sneezing, or blowing your nose, using tobacco, eating or drinking.x. After engaging in any activity that may contaminate the hands.
A review of the facility's policy titled, 3 Compartment Sink- Manual Warewashing Policy, dated April 15, 2024, revealed the following under policy and compliance guidelines, . Warewashing sinks may not be used for handwashing.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 55 105733 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105733 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0881 Implement a program that monitors antibiotic use.
Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49227 potential for actual harm Based on interviews and record reviews the facility failed to monitor antibiotic prescribing practice to reduce Residents Affected - Some antibiotic resistance in two (#38 and #85) of two residents reviewed for long term antibiotic use.
Findings included:
1. Review of Resident # 85's admission record showed 5/13/24 initial admitted and 2/17/25 readmitted with diagnoses to include sepsis due to Methicillin Resistant Staphylococcus Aureus (MRSA) and Extended Spectrum Beta Lactamase (ESBL) resistance.
Review of Resident #85's order summary report, active orders as of 5/15/25 showed Cephalexin 500mg give 1 capsule three times a day for infection until 4/2/26.
Review of Resident #85's care plan, revised on 4/3/25 showed the following focus: resident is at risk for side effects of antibiotic therapy related to sepsis, 4/2/25 now on prophylaxis PO (oral) treatment for one year Goal: Resident # 85 will tolerate antibiotic therapy without complications. Interventions to include medications as ordered, monitor for signs and symptoms of intolerance of antibiotic, observe for diarrhea, rash, stomach issues, etc. and report any issues associated with the use of antibiotic.
Review of a Resident #85's progress note from a local hospital, dated 2/9/25 showed Infectious Disease recommends .oral suppressive antibiotics with Keflex 500 4 times daily for 1 year.
During an interview on 5/15/25 at 4:13 P.M. with the Director of Education (DOE)/ Infection Preventionist (IP) said on 2/17/25 Resident # 85 was added to the facility's antibiotic surveillance log and was removed from
the log when intravenous antibiotic was discontinued. The DOE, IP said Resident #85 will receive antibiotics indefinitely for chronic immunosuppressive therapy.
During an interview on 5/15/25 a 4:49 P.M. the Director of Nursing (DON) said the duration of antibiotic it is up to the physician if (the antibiotic) deemed to need long term.
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2. On 05/14/2025 at 8:34 a.m. Resident #38 was observed dozing in bed. Her breakfast was on her overbed table. The head of the bed was elevated.
Resident #38 was admitted on [DATE REDACTED]Review of the Admission Record showed diagnoses included but not limited to after care following a total knee replacement, sepsis due to Methicillin Resistant Staphylococcus Aureus (MRSA), infection and inflammatory reaction due to internal left knee prosthesis, intraspinal abscess and granuloma, enterocolitis due to clostridium difficile, difficulty in walking, heart failure, Rheumatoid arthritis. Review of the Minimum Data Set, dated dated dated [DATE REDACTED] showed Section C, Cognitive Patterns, Brief Interview for Mental Status of 12, cognitively intact.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 55 105733 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105733 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0881 Review of physician orders showed Cephalexin (Keflex) 500 mg twice day for MRSA left knee, suppressive therapy for life, no stop date as of 03/03/2025. Level of Harm - Minimal harm or potential for actual harm Review of the Antibiotic Time Out dated 02/24/2025 showed Cephalexin 500 mg twice day. admitted on [DATE REDACTED] with diagnosis of MRSA chronic to left knee wound. Evaluated the antibiotic with resident's medical Residents Affected - Some provider. Continue with current antibiotic therapy. Discussed with provider the present Keflex antibiotic therapy with MRSA of left knee wound. Per hospital infectious disease physician, resident to remain on antibiotic therapy for chronic immunosuppression due to history of MRSA in past.
Review of the care plans showed Antibiotics lifetime immunosuppression for history of MRSA as of 03/25/2025. Interventions included enhanced barrier precautions for history of MRSA as of 03/25/2025. Medication per order, notify MD for any concerns as of 03/25/2025.
Review of the Hospitalist Progress Note dated 02/23/2025 showed Keflex 500 mg twice a daily, chronic suppressive therapy for life. Call Infectious Disease Doctor for refills.
During an interview on 05/15/2025 at 11:20 a.m. the Director of Nursing (DON) stated that Resident #38 was
on Keflex for MRSA, suppressive therapy for life. The DON stated the ID doctor put her on it. The DON stated the resident came from the hospital on that medication. The DON stated the Infection Control Preventionist (ICP) was following her, because of on the antibiotic. The DON stated she did not know if it was appropriate to be on long term antibiotic or not they were just following the ID doctors orders.
During an interview on 05/15/2025 at 1:21 p.m. ICP stated Resident #38 came from the hospital with the antibiotic order from the ID doctor. ICP state they did not want us to take her off of the medication. The ICP stated he did not call the ID doctor personally to verify the orders. The ICP stated there were extensive notes from the hospital. The ICP stated he had heard of some cases in the past, where residents were left on long term antibiotics. The ICP stated Resident #38 did not have c-diff issues or was immune compromised. The ICP stated they had her on Enhanced Barrier Precautions (EBP) but was not following her on Antibiotic Stewardship. The ICP stated we have not been following her, we would only follow her if she had symptoms.
The ICP stated she was on EBP due to the MRSA, she was compromised.
The ICP stated we followed her initially, February 24, 2025. The ICP stated when she was admitted in February she had c-diff and MRSA in her surgical incision of the left knee. The ICP stated the c-diff resolved.
The ICP stated the initial MRSA infection colonized and resolved. The ICP stated the Keflex was for the MRSA of the left knee and the chronic suppression for life came from the ID doctor. The ICP stated she was treated for a Urinary Tract Infection on 04/15/2025 and we followed her in Antibiotic Stewardship. The ICP stated the process was the resident to come off the Antibiotic Stewardship tracking when the resident finishes the antibiotic and not symptomatic anymore. The ICP stated if the resident was symptomatic we would be monitoring her again. The ICP stated he would be alerted to her having symptoms through the morning report which includes elevated temperature, change in condition, adverse vital signs, or other symptoms she may be having. The ICP stated we would then go through the Antibiotic Stewardship using
the evidence-based surveillance criteria system.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 55 105733 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105733 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0881 During an interview on 05/15/2025 at 4:39 p.m. the DON, verified order for Keflex 500 mg bid for life. The DON stated the ID doctor ordered it. The DON stated the new hospital record showed the resident was to be Level of Harm - Minimal harm or on Keflex 500 mg twice a day and to call the ID doctor for refills. The DON stated she did not call the ID potential for actual harm doctor regarding the order. The DON stated they have seen the same order before from these ID doctors.
Residents Affected - Some The DON stated verified the hospitalist wrote the order on the hospital record. The DON stated the purpose of Antibiotic Stewardship was to try to ensure not to over utilize antibiotics. The DON stated the Medical Director was also the resident's medical provider in the facility. The DON stated the medical provider was writing the resident's orders for the Keflex now. The DON stated it would be up to her ID doctor or the medical doctor to review the antibiotic orders. The DON stated it was up to the medical provider, and they deem it (antibiotic) was for life. The DON stated it was up to the ID or the medical doctor to review.
3. Review of the facility's policy, Infection Prevention and Control Manual Antibiotic Stewardship & MDROs, effective 2020 showed it is the policy of this facility to provide efforts to optimize the use of antibiotics in order to maximize their benefits to residents, while minimizing both the rise of antibiotic resistance as well as adverse effects to patients from unnecessary antibiotic therapy. Antibiotic Stewardship will include an assessment process, use of evidence based criteria, efforts to identify the microbe responsible for disease, selecting the appropriate antibiotic along with documentation indicating the rational for use appropriate use dosing, route, and duration of antibiotic therapy; and to ensure discontinuation of antibiotics when they are no longer needed procedure
6. Prophylactic medication used in the facility will be limited based on practitioner documentation of rationale, risk, and benefits for use.
Review of the facility's policy, Infection Prevention and Control Manual Antibiotic Stewardship & MDROs, effective 2020 showed antibiotic stewardship refers to systematic efforts to optimize the use of antibiotics - not just reduce the total volume used - to maximize their benefits to patients, while minimizing both the rise of antibiotic resistance as well as adverse effects to patients from unnecessary antibiotic therapy.
The CDC indicates that antibiotics are among the most frequently prescribed medications in nursing homes with up to 70% of residents receiving at least one antibiotic when followed for over one year. The CDC defines Antibiotic Stewardship as a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use.
Stewardship involves identifying the like microbe responsible for disease, utilizing evidence based definitions when indicated; selecting the appropriate antibiotic along with documentation indicating the rationale for use, appropriate dosing, route, and duration of antibiotic therapy; and to ensure discontinuation of antibiotics when they are no longer needed.
There are 7 core elements for Antibiotic Stewardship and nursing homes outlined by the CDC:
Leadership Commitment
Accountability
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 55 105733 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105733 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0881 Drug expertise
Level of Harm - Minimal harm or Action potential for actual harm Tracking Residents Affected - Some Reporting
Education
Leadership Commitment: a well-defined leadership commitment to include:
Policies and Procedures including evidence-based standards of practice promoting a judicious process for antibiotic use in the organization
A solid communication system including nursing staff and prescribing practitioners including their organization system (policies, procedures, and protocols) for the use of antibiotics. This communication includes a system to identify any potential prescribing concerns to the infection preventionist, DON, Pharmacy Consultant and Medical Director for appropriate follow up timely.
Culture change - the entire organization through education and support that promotes compliance with the organization's commitment to appropriate antibiotic use, monitoring, surveillance, tracking and correction of any identified concerns timely in an effort to provide quality care based on standards of practice.
Accountability: The organization will identify positions that will have the authority to hold others accountable for compliance with the facility antibiotic stewardship program.
Medical Director: Responsible for ensuring standards of antibiotic prescribing for quality are set and followed for the care of residents in the facility.
DON: Responsible for ensuring proper Policies, Procedures and Protocols for care are in place to include the entire nursing process (assessment, plan, implementation, and follow up) for use of antibiotics in the care of
the residents. The role of the DON will include adequate education and monitoring, to ensure the process is implemented, proper communication, evidence-based standards of practice vs. perceptions and expectations of all staff and their respective roles.
Infection Preventionist: The IP will be responsible for surveillance, infection definition based on standards of practice, education, tracking, data management, analysis of data, communication with the DON, Medical and Consultant Pharmacists and ongoing system review.
Drug Expertise: Organizations will want to ensure facility staff has the ability to consult and receive support from experts (Pharmacy Consultant, Physicians, etc.) that have received specialized training in infectious diseases and / or antibiotic stewardship.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 55 105733 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105733 B. Wing 05/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Pinellas 200 16th Ave SE Largo, FL 34641
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0881 Tracking and Reporting: Tracking and reporting of antibiotic use and outcomes will be completed in the facility to identify adherence to facility policies and procedures, use and outcomes. Tracking will allow the Level of Harm - Minimal harm or facility to identify patterns, prevalence of antibiotic use as well as specific ordering data. Outcomes (i.e. potential for actual harm adverse drug events, antibiotic resistant organisms, C- difficile infections, etc.) will be tracked by the Infection Preventionist and discussed with the Quality Assurance Committee for action planning. Residents Affected - Some Education: Education on antibiotic stewardship will be provided to facility staff, practitioners, residents, and families / responsible parties. Educational programs provided to families can assist with understanding and work towards reduction in perceptions and misconceptions on the use of antibiotics in nursing homes.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 55 105733