Palm Garden of Pinellas

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Apr 10, 2024

  Based on observations, interviews and record reviews, the facility failed to protect the resident's right to be free from neglect by not ensuring one resident (#1) of six residents at risk for elopement with a known history of exit seeking behaviors, and an expressed desire to leave the facility, was provided supervision and services to prevent elopement. Resident #1, on 3/25/2024 at approximately 4:15 p.m., exited the facility without being seen by staff members. Resident #1 exited through an ambulance side (C-Wing) entrance door of the facility, which was equipped with an electromagnetic locking device (a magnetic lock that was unlocked when de-energized and required power to remain locked). […]

• Immediate jeopardy, isolatedF689Apr 10, 2024

  Based on observations, interviews, and record review, the facility failed to ensure one resident (#1) of six residents at risk for elopement, was provided with supervision and services related to the resident's cognitive deficits, lack of safety awareness, and confusion before admission to the facility. The facility staff failed to ensure the supervision and safety of Resident #1 on 3/25/2024 at approximately 4:15 p.m. Resident #1 exited the facility through an ambulance side (C Wing) entrance door that was equipped with an electromagnetic locking device (a magnetic lock that unlocked when de-energized and required power to remain locked). Resident #1 was able open the door by punching the security code into the keypad beside the door. […]

• Actual harm, isolatedF684May 12, 2026

  Based on interviews and record review, the facility failed to provide care and treatment in accordance with professional standards and failed to send the resident to higher level of care, upon request for one (Resident #2) of two residents sampled. Resident #2 experienced a change of condition on [DATE] with a delay treatment according to professional standard of practice. Cross-reference F580. Findings included:Review of Resident #2's medical record revealed she was admitted to the facility on [DATE] and expired on [DATE]. Resident #2 had a primary diagnosis of heart failure, unspecified and additional diagnoses included type 2 diabetes mellitus with diabetic neuropathy, unspecified; essential (primary) hypertension; and hyperlipidemia, unspecified. […]

• No harm, potential for more than minimal, widespreadF812May 15, 2025

  Based on observations and interviews, the facility did not ensure food safety standards were followed, in the kitchen and two of two nourishment rooms, as evidenced by improper infection control practices including hand hygiene, ice buildup in the walk-in freezer, the dish machine and dumpster areas not maintained in a clean sanitary condition, and resident food items were not labeled/dated. Findings included: On 5/12/25 at 9:28 a.m., an initial tour of the kitchen was conducted. An interview and observation of Staff Q, Culinary Assistant was conducted while he was utilizing the dish machine. An observation of the top of the dish machine revealed a plastic water bottle. […]

• No harm, potential for more than minimal, widespreadF880May 15, 2025

  Based on observations interviews, and policy reviews the facility failed to ensure, 1. Respiratory equipment and supplies were dated and stored in a sanitary manner in seven rooms (134, 133, 143, 137,113, 120 and 126) of 65 rooms toured, and did not ensure Hand Hygiene was performed during two medication administration observations and 3. failed to ensure hand hygiene was performed during dining and kitchen tours during two (5/12/25 and 5/14/25) of four days of survey and 4. did not ensure clean linen was handled in a manner to prevent cross contamination during one of one laundry facility tours. Findings Included: 1. During a tour on 5/12/25 at 9:29 A.M. […]