Palm Garden Of Port Saint Lucie

F-F695).

On 03/25/24, the nursing progress notes revealed there was a rash on the right side of the resident's back. There was no physician notification or follow-up pertaining to the rash on the back documented.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 1 of 13 105600 Department of Health & Human Services Printed: 09/17/2025 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 105600 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Palm Garden of Port Saint Lucie 1751 SE Hillmoor Drive Port Saint Lucie, FL 34952

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 0684 The resident had significant weight gain from her admission on 12/18/23 until the transfer date of 05/19/24. There was a total weight gain of 16 pounds (approximately 13%) during this 5-month period. There were Level of Harm - Minimal harm or nutritional notes in the progress notes stating there was weight gain and to continue the plan of care, with the potential for actual harm last note being on 05/05/24. The resident was on a regular diet with no other nutritional interventions. The resident was consuming 26-75% of meals. There was no other explanation of the weight gain for this Residents Affected - Few resident found in the record.

On 05/15/24, a nursing progress note revealed the resident had pitting edema bilaterally to the lower extremities. The provider was made aware and ordered Lasix (a diuretic) 20 mg tablet by mouth to be administered every morning for 3 days. No further assessments were noted in the nurses' notes regarding

the edema. There were no physician or nurse practitioner notes in the record regarding edema since this order on 05/15/24.

On 05/19/24, the resident was transferred to a higher level of care per family request. The family was concerned due to the patient not speaking clearly and all extremities were red and swollen. Further review of Resident #303's record did not reveal any assessments related to the edema, respiratory, or speech concerns, apart from the assessment done by the weekend supervisor on 05/19/24 after the family's request to send the resident to the hospital.

The last quarterly Minimum Data Set (MDS) completed on this resident was done on 04/21/24 which revealed this resident had clear speech and made self understood. There were no further nurses' notes in

the record regarding any changes to the resident's speech.

Review of the care plan dated 01/29/34, for Resident #303 included a care plan for potential complications related to diagnosis of Hypertension, and the use of diuretic. The interventions included, in part, to observe and report to the nurse or physician any edema, headache, tingling or numbness in the extremities, dizziness, pain, lightheadedness / blurred vision, palpitations, urinary retention, shortness of breath or generalized weakness. If edema is present, encourage the resident to elevate the effected extremity as tolerated. There were no additional care plans related to the resident's edema.

There was no evidence that vital signs were documented for this resident since 03/04/24, apart from the day

the resident was transferred out of the facility. There was an order by the resident's physician to check vital signs twice a day on the morning and evening shift starting on 03/05/24 through the date the resident was transferred. (Refer to

F-F842).

Review of the Emergency Medical Services (EMS) report for the transport of Resident #303 to the hospital emergency department revealed EMS had arrived at the resident at the facility at 1758 (5:58 PM); the resident was sitting upright awake and alert with mumbled speech; the stroke assessment was negative aside from mumbled speech which staff at the facility stated has been like this for over a week; the resident had diffuse pinpoint rash with large darker spots throughout all extremities; the resident felt tired but no itching; Vital signs were stable; and they could not start an IV (intravenous) access due to edema in all extremities.

The resident's record was again reviewed to ensure there were no assessments regarding the change in the resident's speech or the edema to all extremities. There were no assessments or nursing notes located regarding a change in the resident's condition.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 13 105600 Department of Health & Human Services Printed: 09/17/2025 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 105600 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Palm Garden of Port Saint Lucie 1751 SE Hillmoor Drive Port Saint Lucie, FL 34952

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 0684 Review of the hospital emergency department (ED) notes revealed Resident #303 arrived on 05/19/24 at 1824 (6:24 PM). The notes reflected the resident was not talking much, but responded by nodding yes or no. Level of Harm - Minimal harm or She had diffuse swelling over all extremities with and associated petechial rash, and pulseless feet bilaterally potential for actual harm with associated cyanotic changes. The extremities were mottled and cold. The resident's temperature was 91.9 degrees Fahrenheit (F) at 6:37 PM. Further testing and labs completed resulted in a diagnosis of Residents Affected - Few Myxedema coma, which is a life-threatening clinical condition that consists of severe Hypothyroidism with decompensation. The patients are extremely ill with significant hypothermia and depressed mental status.

This condition occurs as an accumulation of waste products and fluids in the body due to low thyroid function. The fluid and waste accumulation in tissues does not resolve with diuretics. Treating the underlying thyroid condition is the only way to resolve Myxedema. Resident #303 was admitted to the intensive care unit (ICU) in critical condition.

A subsequent review of all nurses' progress notes did not reveal a change in the resident's speech or address the edema and rash over all extremities. Vital signs including temperature could not be located in Resident #303's record.

An interview with the Director of Nursing (DON) on 07/25/24 at approximately 10:00 AM revealed the staff do not necessarily document an assessment daily on all long-term care residents and vital signs are done as ordered by the physician.

All the nursing progress notes were requested from the facility on 07/25/24 at approximately 10:15 AM. The Director of Nursing (DON) provided all the nurses notes for Resident #303 at approximately 10:40 AM, stating this was all the nursing progress notes for this resident. The DON confirmed the vital signs were not recorded in the record.

32078

2. Record review documented Resident #36 was admitted to the facility on [DATE REDACTED] with a diagnosis that included Diabetes Mellitus Type 2. Review of the resident's Quarterly Minimum Data Set (MDS) assessment completed on 05/20/24 showed Resident #36 received 7 days of insulin injections during the 7-day look back period. The resident's care plan initiated on 05/15/24 included a plan of care for the diagnosis and treatment of Diabetes.

Review of the current physicians' orders for blood glucose monitoring and Diabetes management were as follows:

a. NovoLog FlexPen Subcutaneous Solution Pen-injector, 100 units\ml; Inject as per sliding scale subcutaneously before meals and at bedtime for DM2 [Diabetes Mellitus 2]:

if 150 - 200 = 2 units;

201 - 250 = 4 units;

251 - 300 = 6 units;

301 - 350 = 8 units;

351 - 400 = 10 units.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 13 105600 Department of Health & Human Services Printed: 09/17/2025 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 105600 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Palm Garden of Port Saint Lucie 1751 SE Hillmoor Drive Port Saint Lucie, FL 34952

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 0684 Over 400, Give 10 units and call MD.

Level of Harm - Minimal harm or Call MD for b\s [blood sugar] under 60. potential for actual harm b. Metformin HCl Oral Tablet, 1000 MG; give 1 tablet by mouth two times a day. Residents Affected - Few c. Humulin N Subcutaneous Suspension, 100 units\ml; Inject 30 units subcutaneously in the morning.

Review of the electronic Medication Administration Record (eMAR) on 07/06/23 at 1630 hours [4:30 PM], revealed Resident #36's blood glucose level was recorded at 53 mg/dl. There was no documentation in the resident's record that the physician was notified of the blood glucose level being below 60.

On 07/17/24 at 1630 hours [4:30 PM], Resident #36's blood glucose level was recorded at 50 mg/dl.

There was no documentation in the resident's record indicating that the physician was notified of the blood glucose level below 60. On 07/17/24 at 20:28 hours [8:28 PM], there was an administration note regarding Metformin HCl Oral Tablet 1000 MG. It documented to hold med due to BS 50 [hold medication due to Blood Sugar 50].

Review of Resident #36's eMAR showed the blood glucose levels were not recorded for the 6:30 AM required testing time for 07/17/24, 07/19/24, 07/21/24 and 07/24/24. Since there were no recorded blood glucose levels on these dates at 6:30 AM, there was no insulin per sliding scale documented as being provided.

Resident #36's Blood Glucose readings within the past 7 days were recorded as follows:

07/17/24:

6 :30 AM - No record

11:30 AM - 121 [mg/dl]

4:30 PM - 50*

9:00 PM - 134.

07/18/24:

6:30 AM - 152

11:30 AM - 204

4:30 PM - 140

9:00 PM - 225.

07/19/24:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 13 105600 Department of Health & Human Services Printed: 09/17/2025 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 105600 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Palm Garden of Port Saint Lucie 1751 SE Hillmoor Drive Port Saint Lucie, FL 34952

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 0684 6:30 AM - No record

Level of Harm - Minimal harm or 11:30 AM - 143 potential for actual harm 04:30 PM - 257 Residents Affected - Few 09:00 PM - 112.

07/20/24:

6:30 AM - 216

11:30 AM - 269

4:30 PM - 98

9:00 PM - 94.

07/21/24:

6:30 AM - No record

11:30 AM - 154

4:30 PM - 241

9:00 PM - 146.

07/22/24:

6:30 AM- 105

11:30 AM - 161

4:30 PM 142

9:00 PM - 98.

07/23/24:

6:30 AM - 114

11:30 AM - 141

4:30 PM - 112

9:00 PM - 151.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 13 105600 Department of Health & Human Services Printed: 09/17/2025 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 105600 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Palm Garden of Port Saint Lucie 1751 SE Hillmoor Drive Port Saint Lucie, FL 34952

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 0684 07/24/24:

Level of Harm - Minimal harm or 6:30 AM - No record potential for actual harm 11:30 AM - 144 Residents Affected - Few No further record review.

On 07/25/24 at approximately 10:00 AM, the Director of Nursing (DON) was notified of the missing documentation in Resident 36's medical record.

On 07/25/24 at 11:42 AM, Resident #36's Primary Care Physician approached me to inform me that the facility staff had notified him when the resident's blood sugar had been below 60. This physician stated, I am going to remove this order [parameters] because the resident's blood sugar has been stable.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 13 105600 Department of Health & Human Services Printed: 09/17/2025 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 105600 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Palm Garden of Port Saint Lucie 1751 SE Hillmoor Drive Port Saint Lucie, FL 34952

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 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 37970 potential for actual harm Based on record review and policy review, the facility failed to ensure the respiratory status of residents were Residents Affected - Few evaluated prior to and after respiratory treatments were administered for 2 of 4 sampled residents reviewed for respiratory services, Resident #14 and 303.

The findings included:

Review of the facility policy, titled, Medication Administration, Nebulizer, M11.0, dated 07/2023 revealed in part, the following:

2. Review and special precautions and perform needed evaluations prior to administering medications to the guest/resident.

Review guest / resident allergies.

Review pertinent lab results, as indicated.

Perform needed evaluations prior to administering specific medications (e.g., pulse, blood pressure, respirations)

7. Evaluate respiratory status.

After the respiratory /nebulizer treatment the policy stated in part:

17. Evaluate respiratory status to include, but not limited to:

Breath sounds.

Cough effort and sputum production.

Heart rate.

Respiratory rate.

1. Review of Resident #14's record revealed the resident was admitted on [DATE REDACTED] with diagnoses including but not limited to Chronic Obstructive Pulmonary Disease (COPD), Hypertension (HTN), Pneumonia, Myocardial Infarction (MI), Dementia, Acute Upper Respiratory Infection, and Heart Failure.

Review of the physician orders, 03/01/24, revealed an order for Albuterol Sulfate Inhalation Nebulization Solution 2.5 mg (milligrams)/ml (milliliter) inhale via nebulizer two times a day for SOB (shortness of breath).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 13 105600 Department of Health & Human Services Printed: 09/17/2025 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 105600 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Palm Garden of Port Saint Lucie 1751 SE Hillmoor Drive Port Saint Lucie, FL 34952

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 0695 Subsequent review of Resident #14's medication administration record (MAR) for July 2024 revealed the nebulizer treatments were administered as ordered. Further review of the record did not reveal respiratory Level of Harm - Minimal harm or assessments were completed prior to and post administration of the nebulizer respiratory treatment. potential for actual harm 2. Review of Resident #303's record revealed the resident was admitted to the facility on [DATE REDACTED] with a Residents Affected - Few diagnosis of Cerebral Atherosclerosis, HTN, Anxiety, Edema, palliative care, and Hyperlipidemia (HLD).

Review of the physician orders revealed an order dated 03/10/24 for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) mg/3ml. Inhale 3ml orally every 6 hours as needed for wheezing. Subsequent review of

the MAR for March 2024 revealed the nebulizer respiratory treatment was administered on 03/10/24, 03/22/24, 03/25/24 and 03/27/24. Further review did not reveal a respiratory evaluation prior to or after the administration of the respiratory treatment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 13 105600 Department of Health & Human Services Printed: 09/17/2025 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 105600 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Palm Garden of Port Saint Lucie 1751 SE Hillmoor Drive Port Saint Lucie, FL 34952

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 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm 39167

Residents Affected - Few Based on interview and record review, the facility failed to ensure narcotic removal was recorded in the Medication Administration Records (MARs) for 2 of 9 sampled residents reviewed. Residents #63 and #97.

The findings included:

1. On 07/24/24 at 9:52 AM, a clinical record review was conducted for Resident #97. The review revealed a physician order of Hydrocodone 5-325 mg by mouth every 4 hours as needed for non-acute pain. The controlled medication utilization record was compared against the July 2024 MARs. There was a discrepancy noted, in which the Controlled Medication Utilization Record showed that the Hydrocodone was removed on 07/05/24 at 6:18 AM and on 07/21/24 at 9:40 PM. The July 2024 MARs lacked documented evidence to reflect this removal and administration to the resident.

On 07/24/24 at 11:19 AM, a side-by-side review of Resident #97's record and interview were held with the second-floor Unit Manager, who acknowledged the above finding.

2. On 07/25/24 at 10:41 AM, a clinical record review was conducted for Resident #63 The review revealed a physician order of Hydrocodone 5-325 mg 1 tablet by mouth every 4 hours as needed for non-acute pain.

The Controlled Medication Utilization Record was compared against the July 2024 MARs. There was a discrepancy noted, in which the Controlled Medication Utilization Record showed the medication was removed on 07/11/24 at 1:00 PM. The July 2024 MARs lacked documented evidence to reflect this removal and administration to the resident.

On 07/25/24 at 10:48 AM, an interview was held with the first-floor Unit Manager. She was made aware of

the lack of documentation on the MARs for the medication administration for Resident #97.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 13 105600 Department of Health & Human Services Printed: 09/17/2025 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 105600 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Palm Garden of Port Saint Lucie 1751 SE Hillmoor Drive Port Saint Lucie, FL 34952

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 0825 Provide or get specialized rehabilitative services as required for a resident.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38212 potential for actual harm Based on record review and interview, the facility failed to provide therapy services as ordered by the Residents Affected - Few physician for 1 of 1 sampled resident, Resident #81, reviewed for rehabilitation therapy.

The findings included:

Record review for Resident #81 revealed the resident was admitted to the facility on [DATE REDACTED] with a diagnosis to include, Type 2 Diabetes Mellitus, Hypertension, Parkinsons Disease, Hyperlipidemia, Systemic Atrophy Primarily Affecting Central Nervous System, Autonomic Neuropathy, Cervical Disc Disorder, Weakness, Pain

in right shoulder and Cognitive Communication Deficit.

On 07/22/24 at 2:35 PM, Resident #81's significant other was interviewed. He stated the resident had neck surgery and she is paralyzed in her right and left extremities. He stated he feels she should be receiving more physical and occupational therapy because he didn't feel Resident #81 was progressing. He stated he wants the resident to be able to walk and he wants her to go home.

On 07/24/24 at 9:21 AM, an interview was conducted with the Director of Therapy Services. He stated Resident #81 is receiving Physical therapy, (PT) 2 times a week and Occupational Therapy (OT) 3 times a week.

Resident #81's record was reviewed. On 07/05/24, a physician order was written for Resident #81 to increase OT to 5 times a week. On 07/25/24 at 8:58 AM, the Director of Therapy Services was asked about

the order for increasing the OT. He stated the resident needs to be assessed and the physician needs to sign the order. The order was reviewed, and the physician signed the order on 07/08/24. The Director of Therapy Services agreed the order had not been initiated.

On 07/25/24 at 11:50 AM, the Director of Therapy Services was interviewed concerning orders the process once the physician enters an order. He stated the OT department receives the order and then does the recertification. The OT department is responsible for entering it into the electronic medical record. When he receives the information from OT, he does the projection (scheduling). He stated it was an oversight technique error from the OT department.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 13 105600 Department of Health & Human Services Printed: 09/17/2025 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 105600 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Palm Garden of Port Saint Lucie 1751 SE Hillmoor Drive Port Saint Lucie, FL 34952

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 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 37970

Residents Affected - Few Based on record review and interview, the facility failed to ensure vital signs were documented as ordered for 1 of 4 sampled residents reviewed for vital signs, Resident #303.

The findings included:

Review of Resident #303 record revealed the resident was admitted on [DATE REDACTED] with diagnoses that included Cerebral Atherosclerosis, Hypertension (HTN), Anxiety, Edema, palliative care, and Hyperlipidemia.

Review of the physician orders dated 03/05/24 included an order to obtain vital signs every shift, day and evening shift.

Review of the Medication Administration Record (MAR) revealed the vital signs were signed off as being completed. Further review of the MAR failed to document any of the vital signs.

Review of the vital signs record did not reveal vital signs were documented after 03/04/24, apart from the day

the resident was transferred out via emergency medical services (EMS) to the hospital at 1839 (6:39 PM).

Review of the nursing progress notes did not have any documentation regarding vital signs.

On 07/25/24 at approximately 10:00 AM, the Director of Nursing (DON) provided a copy of all nursing documentation and confirmed this was all the documentation for Resident #303.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 13 105600 Department of Health & Human Services Printed: 09/17/2025 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 105600 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Palm Garden of Port Saint Lucie 1751 SE Hillmoor Drive Port Saint Lucie, FL 34952

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** 39167 potential for actual harm Based on policy review, observation, interview and record review, the facility failed to ensure the infection Residents Affected - Few control process was followed during pericare for 2 of 2 sampled residents reviewed for Urinary Tract Infection (UTI), Residents #37 and #46.

The findings included:

Review of the policy, titled, Infection Prevention and Control Manual Guidance for control ESBL [Extended Spectrum Beta-Lactamase], dated December 2020, indicated the following, in part: ESBL are enzymes that mediate resistance to extended spectrum (third generation) cephalosporins (e.g. ceftazidime, cefotaxime, and ceftriaxone) and monobactams (e.g. aztreonam) but do not affect cephamycins (e.g. cefoxitin and cefotetan) or carbapenems (e.g. meropenem or imipenem). The purpose was to provide guidelines for presentation and control of ESBL. Clinical symptoms include: cause a range of clinical infections including infections of the urinary tract, bloodstream, surgical site, and intra-abdominal site. Gowns indicated for activities where skin or clothing will come in contact with the patient or their environment in acute care, or when performing direct care.

Review of the policy, titled, Transmission-Based Precautions [TBP], dated December 2020, revealed the following, in part, transmission-based precautions shall only be used when transmission cannot be reasonably prevented by less restrictive measures. Transmission based precautions are divided into: contact precautions, droplet precautions, and airborne precautions. Contact precautions: wear PPE (personal protective equipment) gown and gloves for all interactions that may involved contact with the resident or potentially contaminated areas in the resident environment.

1. Clinical record review for Resident #37 revealed the resident was initially admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses that included: Non-Alzheimer's Dementia, and Parkinson's disease. The quarterly comprehensive assessment, reference date 06/11/24, recorded a brief interview for mental status score of 04, which indicated Resident #37 was severely cognitively impaired. No mood or behavior concern was revealed in this assessment. This assessment evidenced, Resident #37 had required supervision assistance with toilet, and required substantial to maximal assistance with personal hygiene. Additional review of Resident #37's clinical record revealed physician order dated 07/18/24 for urinalysis, culture and sensitivity, the result with reported date 07/19/24, showed evidence of positive for UTI and the culture dated 07/21/24 showed evidence of ESBL in the urine. The physician order dated 07/21/24 for Ertapenem (antibiotic) 1 GM intravenously (IV) in the evening for UTI for 7 Days.

On 07/24/24 at 10:18 AM, pericare observation was conducted on Resident #37, and the care was rendered by Staff B, Certified Nursing Assistant (CNA). When the surveyor entered the room, Staff B had already donned gloves and gown waiting for the surveyor to come and observe the care. Observations revealed: Staff B touched the curtain to close it with the gloves; touched the bed remote to put the resident's head down with the gloves; touched the bed linens to bring the linens down with the gloves; and subsequently, with the same gloves, Staff B obtained a washcloth, applied soap, soaked it in water, and started the pericare.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 13 105600 Department of Health & Human Services Printed: 09/17/2025 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 105600 B. Wing 07/25/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Palm Garden of Port Saint Lucie 1751 SE Hillmoor Drive Port Saint Lucie, FL 34952

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 At 10:26 AM, Staff B's hands were observed wet, as the water had gotten inside the gloves. Staff B removed

the gloves and applied new gloves without hand hygiene in between the gloves being changed. After the Level of Harm - Minimal harm or care was rendered, an interview was held with Staff B, who acknowledged the findings. potential for actual harm 2. Record review revealed Resident # 46 was admitted to the facility on [DATE REDACTED] with diagnoses that included Residents Affected - Few Depression. The annual comprehensive assessment, reference date 06/06/24, evidenced a Brief Interview for Mental Status score of 08, indicating Resident #46 was moderately cognitively impaired. The assessment recorded no mood or behavior concern. This assessment revealed Resident #46 was always incontinent with bladder. Resident #46 required partial to moderate assistance with toileting hygiene and required substantial to maximal assistance with personal hygiene.

Review of the physician's order, dated 07/16/24, documented an order was recieved for urinalysis and culture and sensitivity (Urine C&S) for stomach pain. The result, with reported date 07/17/24, showed evidence of positive for UTI, and the culture dated 07/19/24 showed evidence of ESBL in the urine.

Additional record review evidenced a physician's order dated 07/19/24 for Macrobid 100 MG (antibiotic) by mouth two times a day for UTI for 5 Days. On 07/22/24, a Physician's order was received for Contact Precaution relating to ESBL in the urine.

Review of the clinical record revealed a care plan which indicated Resident #46 had a Urinary Tract Infection, and she was on Contact Precautions for ESBL in the urine.

On 07/22/24 at 8:46 AM, Resident #46's room was observed with a transmission base precaution kit attached to the door, but there were no signs at the door to alert the staff of the precaution.

On 07/24/24 at 10:06 AM, peri care observation was conducted. The care was rendered by Staff A, CNA. Staff A did not wear personal protective equipment (PPE) while doing the care. Staff A's uniform was touching the bed as she provided the care. An inquiry was made regarding PPE usage, and the surveyor asked the CNA why she didn't wear a gown. The CNA revealed she forgot to don a gown.

On 07/24/24 beginning at 10:35 AM, an interview was held with the Director of Nursing (DON). The surveyor informed the DON that Staff A failed to wear a gown while she was providing pericare to Resident #46. The surveyor explained the findings and manner in which the care was rendered to Resident #37, indicating the breach in infection control practices.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 13 105600