Palm Garden Of West Palm Beach
Inspection Findings
F-Tag F0686
F 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record reviews and interviews, the facility failed to ensure care and services to prevent pressure ulcers, as evidenced by no interventions ordered or in place to prevent, 1 of 3 sampled residents, Resident #3, from acquiring pressure ulcers. The findings included:Record review revealed Resident #3 was readmitted to the facility on [DATE REDACTED]. Review of the admission assessment dated [DATE REDACTED] documented Resident #3 had redness to her buttocks area. Review of the quarterly minimum data set assessment dated [DATE REDACTED] documented Resident #3 was dependent on staff for toileting and required moderate assistance for turning right to left in bed.Review of the physician orders for Resident #3 did not reveal any orders to prevent skin breakdown.Review of a skin assessment dated [DATE REDACTED] documented Resident #3 had an open wound to her sacrum and left buttocks.Review of a progress note dated 04/25/25 revealed documentation that staff called Resident #3's daughter to inform her of an open area and redness to the resident's buttocks area. It further stated that staff told the daughter the Resident had non blanchable redness to her buttocks when she returned to the facility and the daughter said she was not aware or informed about the redness.Review of
the care plan did not reveal any documented focus that stated Resident #3 was at risk of developing pressure ulcers.Review of a wound care consult dated 04/28/25 revealed documentation that Resident #3 had a Stage 4 pressure ulcer to the sacrum and a Stage 3 pressure ulcer to the left buttocks. During an
interview with the Director Of Nursing (DON) on 12/29/25 at 4:18 PM, she was asked if Resident #3 had facility acquired pressure ulcers. She stated, I pulled some information regarding her wounds; let me get it for you. The DON returned with copies of progress notes regarding other skin issues the resident had.
When asked if she was aware of when Resident #3 got the pressure ulcers to her sacrum and left buttocks and if there were any interventions in place to prevent them, she stated I wasn't here at that time. I will get
the person that does the care plans.During an interview on 12/29/25 at 4:25 PM, Staff A, Care Plan Specialist, Staff A was asked if there were any interventions ordered or in place to prevent Resident #3 from getting pressure ulcers. She looked in her computer and stated, I see a care plan that was initiated on 04/22/25 that said she was at risk and is being treated for pressure ulcer. When asked whether there was anything prior to her getting the pressure ulcers, she stated, No I don't see anything care planned.
Residents Affected - Few
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 REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
PALM GARDEN OF WEST PALM BEACH in WEST PALM BEACH, FL inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
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 WEST PALM 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 WEST PALM BEACH or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.