Palm Garden of Orlando

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Jul 25, 2024

  Based on observation, interview, and record review, the facility failed to implement appropriate interventions to mitigate elopement risk and failed to provide adequate supervision to maintain a secure environment to ensure vulnerable residents did not exit the facility without supervision for 1 of 9 residents reviewed for elopement, out of a total sample of 9 residents, (#1). These failures contributed to the elopement of resident #1 and placed him at risk for serious injury/impairment/death. […]

• Immediate jeopardy, isolatedF689Mar 25, 2021

  Based on observation, interview and record review, the facility failed to provide adequate supervision to ensure vulnerable residents did not exit the facility unnoticed, and failed to secure and monitor doors to maintain a safe and secure environment for 1 of 9 residents reviewed for elopement risk, of a total sample of 45 residents, (#75). These failures contributed to resident #75 wandering to unsafe places and placed her at risk for serious injury/impairment/death. While resident #75 was out of the facility unsupervised, there was high likelihood she could have fallen, gotten lost or been hit by a car if she had reached the nearby parking lot or street. […]

• Actual harm, isolatedF684Sep 30, 2024

  Based on interview and record review, the facility failed to ensure effective communication and collaboration between members of the interdisciplinary team and hospice to provide the necessary care and services to attain the highest practicable well-being before and after a fall for 1 of 5 residents reviewed for falls, of a total sample of 9 residents, (#1). The facility's failure to follow the physician's orders and treat pain and discomfort after a change in condition resulted in actual harm. Findings: Cross reference F725 and F849 Review of resident #1's medical record revealed she was originally admitted to the facility on [DATE] and readmitted on [DATE] from an acute short-term hospital. Her diagnoses included heart failure, type 2 diabetes, neuropathy, anxiety, and anemia. […]

• No harm, potential for more than minimal, patternF847Nov 7, 2024

  Based on interview, and record review, the facility failed to ensure the binding arbitration agreement explicitly granted the resident or their representative the right to rescind the agreement within 30 calendar days of signing it for 76 of 76 residents who signed the arbitration agreement during the time of the survey. Findings: Review of the log provided by the facility at the time of survey revealed 76 of the current 125 residents signed the facility's arbitration agreement. On 11/07/24 at 12:35 PM, the Director of Guest Services stated she was responsible for meeting with the resident/resident representative post-admission to get the admission packet signed. She verified the admission agreement included the arbitration agreement. […]

• No harm, potential for more than minimal, patternF609Dec 27, 2022

  Based on interview, and record review, the facility failed to report alleged violations timely for 2 of 2 residents reviewed for injuries of unknown origin of a total sample of 4 residents, (#2, #1). Findings: 1. Review of resident #2's medical record revealed he was admitted to the facility on [DATE] from an acute care hospital with diagnoses of stroke, hemiplegia, spondylosis, seizures, cognitive communication deficit and pneumonia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11/15 that indicated he was moderately cognitively impaired. […]