Palm Garden of Ocala

In the surveyor’s words

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

• Actual harm, isolatedF689Dec 19, 2024

  Based on interview and record review the facility failed to ensure adequate supervision during toileting to prevent an accident resulting in head injury and transferred to a higher level of care for 1 of 3 residents reviewed for accident prevention (Resident #1). Findings include: Review of Resident #1's admission record documented diagnosis to include wedge compression fracture of first and fifth lumbar vertebra, Huntington's Disease, and ataxia (poor muscle control that affects balance and coordination). Review of the fall risk assessment for Resident #1 dated 12/14/2024, revealed a score of 13. A Score 10 or higher indicated the resident is at high risk of falls. Review of Resident #1's progress note dated 12/18/2024 documented, Late entry. […]

• No harm, potential for more than minimal, widespreadF812Jan 26, 2021

  Based on observation and interview, the facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety when not testing food temperatures on the tray line in a safe and sanitary manner; this has the potential to affect the resident population of 132 residents. Findings include: During an observation for temperature compliance on the breakfast tray line, Staff O, Cook used a digital thermometer to obtain food temperatures. […]

• No harm, potential for more than minimal, patternF656Jun 12, 2025

  Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan for 1 of 2 residents reviewed for accidents (Resident #70), 2 of 5 residents reviewed for insulin administration (Residents #82 and #167), and 1 of 8 residents reviewed for oxygen therapy (Resident #166). Findings include: 1) During an observation on 6/10/2025 at 8:07 AM, Resident #70 was lying in bed. The bed was in a low position. There was one fall mat on the right side of the bed. There was a fall mat stored behind a chair in the resident room (Photographic evidence obtained). During an observation on 6/11/2025 at 7:54 AM, Resident #70 was lying in bed. The bed was in a low position. There was one fall mat on the right side of the bed. […]

• No harm, potential for more than minimal, patternF695Jun 12, 2025

  Based on observation, interview, and record review, the facility failed to ensure residents received respiratory care as ordered by physician for 4 of 8 residents reviewed for respiratory services (Residents #19, #66, #166 and #51). Findings include: 1) During an observation on 6/9/2025 at 9:27 AM, Resident #19 was in bed, receiving oxygen at 4 liters per minute via nasal cannula. The oxygen concentrator was on the left side of the bed outside of the resident's reach. During an interview on 6/9/2025 at 9:27 AM, Resident #19 stated, I don't touch the oxygen. The nurses do that. They take it off and put it on for me. Review of Resident #19's physician order dated 2/20/2025 read, Oxygen at 2 LPM [liters per minute] via N/C [nasal cannula] PRN [as needed] as needed for Shortness of Breath. […]

• No harm, potential for more than minimal, patternF880Mar 7, 2024

  Based on observation, interview, and record review the facility failed to prevent the possible spread of infection for residents on contact isolation, during hydration pass, and medication administration. Findings include: 1) Review of the admission record for Resident #52 documented diagnosis to include acute kidney failure, type 2 diabetes mellitus, chronic kidney disease stage 3, personal history of transient ischemic attack (TIA) and cerebral infarction (a stroke) and essential (primary) hypertension. Review of the document titled, Lab results report for Resident #52 dated 3/3/2024 read, C. [Clostridium] Difficile Molecular [a highly sensitive and specific test for the presence of a toxin-producing C. difficile organism] result positive. […]