Palm Garden of Jacksonville

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Nov 19, 2021

  Based on observations, interviews, and record reviews, the facility failed to ensure the residents' right to be free from neglect due to an Agency nurse's failure to respond when repeatedly notified of a resident's change in condition, including agitation, restlessness, and numerous attempts to jump out of bed for one (Resident #191) resident with a history of falls, behaviors and suicidal ideation, out of four residents reviewed, and from a total of 37 residents in the sample. The facility's failure to ensure Resident #191 was cared for appropriately, contributed to the resident's death. The facility's employees and service providers failed to provide services to Resident #191 that were necessary to avoid physical harm. During the 3:00 p.m. to 11:00 p.m. […]

• Immediate jeopardy, isolatedF684Nov 19, 2021

  Based on interviews and record reviews, the facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive, person-centered care plan, by failing to 1) Ensure an Agency nurse appropriately assessed a resident's change in condition, including agitation, restlessness, and numerous attempts to jump out of bed for one (Resident #191) resident with a history of falls, behaviors, and suicidal ideation, out of four residents reviewed. The facility failed to ensure the Agency nurse recognized and addressed an emergent situation for a fall-risk resident, which contributed to her death. […]

• Immediate jeopardy, isolatedF726Nov 19, 2021

  Based on interviews and record reviews, the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to ensure resident safety, by failing to ensure the nursing staff recognized and managed a resident's change in condition, including agitation, restlessness, and numerous attempts to jump out of bed for one (Resident #191) resident with a history of falls, behaviors and suicidal ideation, out of four residents reviewed, from a total of 37 residents in the sample. The facility's failure to ensure nursing staff maintained appropriate skills sets and competencies contributed to Resident #191's death. The facility's employees and service providers failed to provide services to Resident #191 that were necessary to avoid physical harm. […]

• Immediate jeopardy, isolatedF742Nov 19, 2021

  Based on interviews and record reviews, the facility failed to ensure that a resident with a history of trauma and/or post-traumatic stress disorder, received appropriate treatment and services to correct the assessed problem or to attain their highest practicable mental and psychosocial well-being, by failing to ensure an Agency nurse appropriately assessed a resident's change in condition, including agitation, restlessness, and numerous attempts to jump out of bed for one (Resident #191) resident with a history of post-traumatic stress disorder ([CONDITION(S)]), behaviors and suicidal ideation, out of four residents reviewed. The facility failed to ensure the Agency nurse recognized and addressed an emergent situation for a resident with [CONDITION(S)], which contributed to her death. […]

• Immediate jeopardy, isolatedF867Nov 19, 2021

  Based on interviews, record reviews, and a review of the facility's policy and procedure for Quality Assurance Performance Improvement (QAPI), the facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies, particularly those that cause adverse outcomes. This resulted in a lack of improvement of their systems and processes, and contributed to Resident #1's death. The facility's employees and service providers failed to provide services to Resident #191 that were necessary to avoid physical harm. During the 3:00 p.m. to 11:00 p.m. […]