Palm Garden of Sun City

In the surveyor’s words

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

• Actual harm, isolatedF600May 6, 2025

  Based on interviews, record review, and policy review, the facility failed to protect the resident's right to be free from neglect related to not ensuring a safe transfer from a wheelchair to a bed for one resident (Resident #2) of three sampled residents requiring staff assistance with a mechanical lift for transfers. This failure created a situation where the resident fell from the mechanical lift to the floor, causing injuries resulting in transfer to a higher level of care for treatment. Findings included: Review of Resident #2's nurse progress notes dated 4/22/2025 at 6:23 p.m. and authored by Staff A, Licensed Practical Nurse (LPN), revealed the following Nursing Note: Writer was notified by [Certified Nursing Assistant] CNA that [Resident #2] was on floor. […]

• Actual harm, isolatedF600Sep 10, 2024

  Based on observations, interviews, and record review the facility failed to protect the right to be free from neglect related to pain management, contracture management, activities of daily living (ADL) care, and seating systems for one resident (#91) out of 38 total sampled residents. Findings included: On 9/7/24 at 3:31 p.m., Resident #91 was lying in bed with bilateral upper extremities contracted. No palm guards or splints were observed on the resident or in the room. No wheelchair or seating system was observed in the room. Her fingernails extended approximately 1/2 inch past the tips of her fingers with debris underneath and she had hair growth on her chin. The resident stated she didn't know if the staff could clip her nails, but she would like them shorter. […]

• Actual harm, isolatedF697Sep 10, 2024

  Based on observations, interviews, and record review the facility failed to ensure pain was managed for one resident (#91) out of three residents reviewed for pain out of a total sample of 38 residents. Findings included: On 9/7/24 at 3:31 p.m., Resident #91 lying in bed with bilateral upper extremities contracted. No palm guards or splints were observed on the resident or in the room. No wheelchair or seating system was observed in the room. Her fingernails extended approximately 1/2 inch past the tips of her fingers with debris underneath. The resident stated she didn't know if the staff could clip her nails, but she would like them shorter. (Photographic evidence obtained with resident consent). On 9/8/24 at 1:44 p.m., Resident #91 was lying flat in her bed with a left tilt. […]

• No harm, potential for more than minimal, widespreadF812Sep 10, 2024

  Based on observation, interview, and record review the facility failed to ensure dietary staff were wearing hair nets, temperature logs were completed, and food items were labeled, dated, and stored according to professional standards for food safety services in one of one kitchen, one of one dining room, one of two nourishment rooms, and one of one activity room. Findings included: On 09/07/24 at 9:07 a.m., Staff A, Dietary Aide (DA) had no hairnet on while in the kitchen area. Immediate interview with Staff A, Dietary Aide (DA) revealed staff are required to wear hairnets while in the kitchen area. I just forgot to put a hairnet on this morning. On 09/07/24 at 9:11 a.m., a box of bananas was stored on the floor in the dry storage area. […]

• No harm, potential for more than minimal, patternF645Sep 10, 2024

  Based on record review and interview, the facility failed to complete accurate Preadmission Screening and Resident Review (PASRR) forms for four (Resident #15, #19, #24 and #59) of 38 sampled residents. Findings included: 1. Review of the Admission Record showed Resident #19 was admitted on [DATE] with diagnoses to include Major Depressive Disorder and Dementia. Review of Resident #19's PASRR Level I Screen, dated 08/26/2024 Section I, A did not mark the diagnosis of Depressive Disorder. Section II, #7 was not marked for the diagnosis of Dementia. 46234 2. […]