Palm Garden of Clearwater

In the surveyor’s words

From the most serious findings on record at Palm Garden of Clearwater, in the surveyor’s own words.

• Immediate jeopardy, patternF656Aug 8, 2025

  Based on observations, interviews, and record review, the facility failed to ensure staff followed care plan interventions and perform accurate assessments on residents related to bed mobility assistance for three residents (#5, #6, and #7) out of three residents sampled.On 07/25/2025 Staff A, Certified Nursing Assistant (CNA), independently rolled Resident #5 onto her side in bed to perform incontinence care. Staff A, CNA left Resident #5 unattended in bed to collect supplies. […]

• Immediate jeopardy, patternF689Aug 8, 2025

  Based on observations, interviews, and record review, the facility failed to prevent a fall with serious injury for one resident (#5) out of three residents sampled for accidents. On 07/25/2025 Staff A, Certified Nursing Assistant (CNA), independently rolled Resident #5 onto her side in bed to perform incontinence care. Staff A, CNA left Resident #5 unattended in bed to collect supplies. Resident #5 fell out of the bed while unattended and suffered a right hip fracture which required a transfer to a higher level of care and surgical repair.This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to residents and resulted in the determination of Immediate Jeopardy on 08/07/2025. […]

• Immediate jeopardy, isolatedF578Jun 10, 2026

  Based on interviews and record review, the facility failed to honor the Advanced Directive for one resident (#1) out of three residents sampled. On 05/14/2026, facility staff initiated Cardio-Pulmonary Resuscitation (CPR), including cardiac compressions (use of hands to push down hard and fast to manually pump blood through the heart), when Resident #1 was found unresponsive. The resident had a physician order for Do Not Resuscitate (DNR), dated 06/13/2025. Cardiopulmonary Resuscitation was provided to Resident #1 for approximately nine minutes. Failure to honor the resident's wishes caused unnecessary physical and psychosocial harm and denied Resident #1 a peaceful death. […]

• Immediate jeopardy, isolatedF726Jun 10, 2026

  Based on interviews and record review, the facility failed to ensure nursing staff were competent in the identification of code status for one resident (#1) out of three residents sampled. On 05/14/2026, facility staff initiated Cardio-Pulmonary Resuscitation (CPR), including cardiac compressions (use of hands to push down hard and fast to manually pump blood through the heart), when Resident #1 was found unresponsive. The resident had a physician order for Do Not Resuscitate (DNR), dated 06/13/2025. Cardiopulmonary Resuscitation was provided to Resident #1 for approximately nine minutes. Failure to honor the resident's wishes caused unnecessary physical and psychosocial harm and denied Resident #1 a peaceful death. […]

• No harm, potential for more than minimal, widespreadF645Feb 6, 2025

  Based on interview and record reviews, the facility failed to ensure Preadmission Screening and Resident Review (PASRR) assessments were accurate for twelve residents (#1, #126, #44, #97, #71, #119, #116, #60, #90, and #39) out of 32 residents sampled. Findings included: 1. Review of Resident #1's Admission Record showed Resident #1 was admitted to the facility on [DATE] with a primary diagnosis of unspecified dementia. Other diagnoses include major depressive disorder and anxiety disorder. Review of the Level I PASRR dated 11/2/2024 showed in Section II: Other Indications for PASRR Screen Decision-Making, 5. Does the individual have a primary diagnosis of dementia, was marked No. […]