Palm Garden of West Palm Beach

In the surveyor’s words

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

• Immediate jeopardy, isolatedF578Apr 24, 2025

  Based on record review, interview, policy review, and surveillance camera review, the facility failed to ensure a resident's advance directive choices were honored for a resident's expressed wishes for a Do Not Resuscitate (DNR) order for 1 of 4 sampled residents reviewed for DNR status (Resident #1). The deficient practice caused Resident #1 to have likely suffered serious psychological harm by the facility's attempt to be resuscitated against his wishes. Resident #1 could not express his reaction to this event; therefore, the reasonable person concept was applied. Additionally, there was a likelihood that Resident #1 experienced severe physical pain; broken ribs; broken sternum and bleeding in the chest area from the resuscitation efforts (https://pubmed.ncbi.nlm.nih.gov/38206442/). […]

• No harm, potential for more than minimal, isolatedF686Dec 29, 2025

  Based on record reviews and interviews, the facility failed to ensure care and services to prevent pressure ulcers, as evidenced by no interventions ordered or in place to prevent, 1 of 3 sampled residents, Resident #3, from acquiring pressure ulcers. The findings included:Record review revealed Resident #3 was readmitted to the facility on [DATE]. Review of the admission assessment dated [DATE] documented Resident #3 had redness to her buttocks area. Review of the quarterly minimum data set assessment dated [DATE] documented Resident #3 was dependent on staff for toileting and required moderate assistance for turning right to left in bed.Review of the physician orders for Resident #3 did not reveal any orders to prevent skin breakdown.Review of a skin assessment dated [DATE] documented… […]

• No harm, potential for more than minimal, isolatedF561Aug 14, 2025

  Based on observation, record review and interviews, the facility failed to ensure that 1of 3 sampled residents received a shower as evidenced by not providing a shower to Resident #48. The findings included: Record review revealed Resident #48 was readmitted to the facility on [DATE]. Review of the annual comprehensive assessment, dated 08/03/25, documented a Brief Interview Mental Status (BIMS) score of 15 on 0-15 scale, indicating no cognitive impairment. Review of the care plan, dated 08/05/25, revealed Resident #48 required partial assistance with a shower. During an interview on 08/11/25 at 2:46PM with Resident #48's spouse, she stated I have spoken to administration about an issue, and it is still not fixed. […]

• No harm, potential for more than minimal, isolatedF641Aug 14, 2025

  Based on observation, record review, and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for 3 of 31 sampled residents, related to the comatose status for Resident #65, related to diagnosis and oxygen therapy for Resident #77, and related to diagnosis for Resident #96.The findings included:1. Review of the record revealed Resident #65 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #65 was comatose, defined as a persistent vegetative state and no discernible consciousness.An observation and interview were conducted on 08/11/25 at 4:17 PM with Resident #65 was noted lying in bed and moving about. When asked if she was doing OK, the resident nodded her head yes. […]

• No harm, potential for more than minimal, isolatedF656Aug 14, 2025

  Based on interview and record review, the facility failed to develop care plans for 2 of 31 sampled residents, as evidenced by lack of care plans for Resident #8 regarding the administration of diuretics and anticoagulants, and Resident #31 related to assessed trauma.The findings included: 1.Review of the record documented Resident #8 was admitted to the facility on [DATE], and March 27, 2025, with a diagnosis that included Hypertension (high blood pressure). Review of the physician's orders dated March 27, 2025, included the following: Spironolactone 25 mg tablet to be taken once daily in the morning for fluid retention, and Apixaban 2.5 mg oral tablet to be taken twice daily for non-valvular atrial fibrillation. […]