Palm Garden of Largo

In the surveyor’s words

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

• Actual harm, isolatedF689May 20, 2026

  Based on observations, interviews, and record review, the facility failed to ensure the safety of one resident (#2) out of three residents sampled. This failure resulted in a fall with major injury for Resident #2 when the individual care plan for transfer was not followed during a shower. Findings included: On 05/18/2026 at 12:15 p.m. Resident #2 was observed lying down in bed. She stated she was still in pain from the fall she had a week ago during a shower. She stated a Certified Nursing Assistant (CNA) transferred her with the Hoyer Lift without assistance in the shower chair. She stated during her shower she kept telling the CNA she felt like she was going to fall out of the chair. She stated the chair felt like it was falling apart and she knew she was going to fall. […]

• Actual harm, isolatedF600Jun 21, 2025

  Based on observations, interviews, and record review, the facility failed to protect the resident's right to be free from neglect related to: 1) providing timely care and services to prevent physical/emotional discomfort for toileting assistance for one resident (#4) out of five residents sampled, and 2) protecting residents from unsympathetic/negative attitudes from staff for three residents (#6, #7, and #5) out of three residents sampled. These failures resulted in emotional/psychological distress and a fear of retaliation among residents. Findings included: 1. During a facility tour on 6/21/25 at 9:32 a.m., an observation was made of a call light signal on in Resident #4's room. There were no staff observed in the hallway responding the call light. […]

• Actual harm, isolatedF689Feb 29, 2024

  Based on observation, interviews, and record review, the facility failed to ensure three (#320, #62, #321) of four residents reviewed for falls out of a total sample of 53 residents received accurate evaluations of fall risks to ensure adequate supervision, assistance devices, and individualized interventions were implemented to prevent accidents with injuries. Findings included: 1. Review of the Admission Record revealed Resident #321 was originally admitted to the facility on [DATE] with diagnoses to include: history of falling, difficulty in walking, pain in left hip, muscle weakness, unspecified dementia, cognitive communication deficit, essential hypertension, and history of transient ischemic attack (TIA) and cerebral infarction without residual deficits. […]

• No harm, potential for more than minimal, widespreadF645Feb 29, 2024

  Based on record review and staff interviews, the facility failed to complete the Preadmission Screening and Resident Reviews (PASARRs) for residents with a mental disorder and individuals with intellectual disability following qualifying mental health diagnosis for four of four residents sampled for PASARRs (Residents #16, #20, #74 and #71). Findings included: 1. Review of the electronic medical record (EMR) revealed Resident #16 was admitted to the facility on [DATE] with diagnoses to include bipolar disorder date 4/26/23, major depressive disorder date 7/14/23, schizoaffective disorder bipolar type date 6/20/23 and anxiety disorder date 4/26/23. Review of a level I PASARR for Resident #16 dated 04/25/23 showed the qualifying diagnoses were not checked or indicated. […]

• No harm, potential for more than minimal, patternF880May 20, 2026

  Based on observations, interviews, and record review, the facility failed to ensure proper infection control practices were utilized related to contact precautions on two resident units (100 and 200) out of three resident units in the facility.Findings included:An observation was conducted on 5/18/26 at 9:42 a.m. of a staff member entering room [ROOM NUMBER], which had a contact precaution sign on the door. The staff did not use personal protective equipment (PPE) while in the room.An observation as conducted on 5/18/26 at 9:53 a.m. of a staff member in room [ROOM NUMBER], which had a contact precaution sign on the door. The staff member did not have any PPE on while in the room. The staff member exited the room, spoke to the nurse in the hall, reentered the room, then exited again. […]