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Complaint Investigation

Palm Garden Of Vero Beach

April 30, 2026 · Vero Beach, FL · 1755 37th Street
Citations 2
CMS Rating 3/5
Beds 189
Provider ID 105592
Healthcare Facility
Palm Garden Of Vero Beach
Vero Beach, FL  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

PALM GARDEN OF VERO BEACH in VERO BEACH, FL — inspection on April 30, 2026.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0572
Resident Rights Deficiencies

Review of the resident documents lacked any signed admission Agreement.During a side-by-side review of the record and interview on 04/30/26 at 11:17 AM, when asked the process for obtaining a signed admission Agreement with resident rights for a newly admitted resident, the Director of Guest Services stated she would talk with the resident to determine if they were able to understand and sign the agreement, checking their cognition and or checking with social services for a Brief Interview for Mental Status (BIMS) score if needed.

The Director of Guest Services further stated if the resident was cognitively intact, she would go over the admission Agreement and obtain a signature, and if not cognitively intact she would reach out to the Power of Attorney (POA) or spouse or other family member as applicable.

When asked the time frame to complete the admission Agreement, the Director of Guest Services explained that she works part-time at the facility three times weekly, but stated, about 72 hours, depending on if the family was available.

The Director further stated the admission Agreement could be done via eSign (electronic signatures) with an email address.

Upon review of a blank admission Agreement, the prices for services not covered were not filled in on the form.

The Director of Guest Services explained when she populates the form with the date, the prices and or cost of services would automatically populate.During this continued interview, the Director of Guest Services was asked to locate and provide the signed admission Agreement for Resident #2.

The Director of Guest Services looked in the electronic medical record (EMR) and stated there was none.

When asked what happened, the Director of Guest Services stated she did not know but did recall at the time of Resident #2's admission, she was the only person in Guest Services, and she did take a vacation during that time.

When asked about the written notice of costs for services not covered for Resident #2 when her benefits ended, the Director of Guest Services stated the resident or representative would have had a conversation with the Business Office Manager (BOM) and or Social Services Director (SSD) when her insurance benefits ended.

During an interview on 04/30/26 at 11:48 AM, when asked how the resident was informed in writing of the room rates when their insurance benefits ended, both the BOM and SSD agreed the information was in the admission Agreement.

When asked if either had provided Resident #2 or the representative with the costs not covered, both stated they had talked with the resident and daughter daily and informed them of the costs, but that it was verbal conversations with no documentation.

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

105592 04/30/2026

Palm Garden of Vero Beach 1755 37th Street Vero Beach, FL 32960

Review of the hospital discharge instructions included the need for a follow-up appointment with the resident's orthopedic surgeon in two weeks, with the instructions to call for an appointment.

Review of the record revealed an order dated 01/02/26, seventeen days after admission to the facility, for a follow up appointment with the orthopedic surgeon. An orthopedic progress note revealed the resident was seen in the surgeon's office on 01/12/26, four weeks after the procedure.

The record lacked any documented reason for the delay.

During an interview on 04/30/26 at 11:01 AM, the Independence [NAME] Clerk voiced difficulty in scheduling appointments with the orthopedic surgeon of Resident #2.

The [NAME] Clerk reviewed the calendar for Resident #2 and found the appointment scheduled for 01/12/26 at 9:40 AM.

When asked about the 2-week time frame, the [NAME] Clerk stated if the doctor was booked up, they would ask for a verbal order for the wound care nurse to discontinue staples, if needed.

When asked if there was any documentation as to why the appointment was delayed for Resident #2, the [NAME] Clerk stated no, and agreed with the findings.2)

During an interview on 04/29/26 at 2:17 PM, when asked the process when one of her nurse's identified a change in condition in a resident, the Seaway Clinical Services Coordinator (Nurse Supervisor) stated the nurse should do a head to toe assessment with a full set of vital signs, document it on the Change in Condition form, and notify both the physician and family.

When asked specifically about the vital signs, the Clinical Services Coordinator explained they utilize a vital sign machine that will document the vitals taken directly into the electronic medical record (EMR) when they are completed.

The Clinical Service Coordinator confirmed the vitals should include blood pressure, pulse, respirations, and oxygen saturation, was made aware of the following, and agreed with the findings.a)

Review of the record revealed Resident #4 was admitted on [DATE] with a subsequent hospitalization on 03/12/26.

Review of the Change in Condition form dated 03/12/26 at 11:22 PM documented the resident's change was shortness of breath that started that same night.

This form documented the blood pressure, pulse, and temperature from 1:52 PM on 03/12/26, ten hours earlier than the actual event.b)

Review of the record revealed Resident #6 was admitted to the facility on [DATE] with a subsequent hospitalization on 04/12/26.

Review of the Change in Condition form dated 04/12/26 at 9:27 PM documented the resident's change was shortness of breath that started that same night.

This form documented the blood pressure and oxygen saturation from 7:15 AM on 04/12/26, the resident's temperature from 5:49 PM that day.c) Review of the record revealed Resident #9 was admitted on [DATE] with a subsequent hospitalization on 03/29/26.

Review of the Change in Condition form dated 03/29/26 at 2:16 AM documented the resident's change was shortness of breath that started that same morning.

This form documented the resident's pulse from 03/28/26 at 10:04 PM.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in VERO BEACH, FL, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from PALM GARDEN OF VERO BEACH or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.