Palm Garden of Winter Haven

In the surveyor’s words

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

• Actual harm, isolatedF600Apr 4, 2024

  Based on observation, record review and interviews, the facility failed to protect one (#1) resident from witnessed physical abuse by a staff member and failed to protect two residents (#2, #3) following allegations of abuse out of a total sample of four residents. Findings included: 1. During an interview on 04/02/2024 at 12:50 p.m. Staff B, Licensed Practical Nurse (LPN) stated she worked a double on 3/26/24 with Staff A, LPN. Staff A, LPN was with Resident #1, and I heard him state, If you don't stop swearing, I am going to slap the shit out of you. The first time I heard him I was at my med cart down the 40s hall. It was loud enough I could hear it. Staff A, LPN was standing next to the resident's wheelchair; I was probably about 25 feet away. […]

• Actual harm, isolatedF607Apr 4, 2024

  Based on observation, record review and interview, the facility failed to implement the facility's Abuse, Neglect, Exploitation and Misappropriation policy and procedure for witnessed physical abuse of one resident (#1) and allegations of physical and verbal abuse of two residents (#2 and #3) of four sampled residents. Findings included: A review of facility's Abuse, Neglect, Exploitation and Misappropriation Policy and Procedures, last revised September 2023, documented the policy: The center recognizes each resident's right to be free form abuse, neglect, and exploitation (ANE), misappropriation of resident property . […]

• No harm, potential for more than minimal, patternF645Jun 20, 2024

  Based on observations, interviews, and record review, the facility failed to ensure Preadmission Screening and Resident Review (PASRR) assessments were updated to include current diagnoses, for six residents (#74, #10, #69, #43, #65, and #5) out of 45 sampled residents. Findings included: 1. During an observation on 06/17/2024 at 12:30 p.m., Resident #74 was in the dining room eating lunch. Resident #74 reached into his pocket and pulled out a 100 dollar bill and put it on the table and said this is for the staff for doing such a great job. He then picked up the money and stuck it back in his pocket. […]

• No harm, potential for more than minimal, patternF880Jun 20, 2024

  Based on observations, interviews, and record reviews, the facility failed to implement an effective infection control program related to ensuring staff were educated on transmission-based precautions (TBP) and the personal protective equipment (PPE) to be worn when entering isolation precaution rooms, and failed to ensure signage was posted related to the type of TBP for two residents (#44 and #83) out of two residents sampled for isolation precautions. Findings included: On 6/17/24 at 9:54 a.m., an observation was made of the area outside of Resident #44's room. A caddy holding gloves, blue gowns, and red biohazard bags hung on the hallway side of the door. The area outside of the room did not show the type of PPE staff were to wear or when to wear PPE during the care of Resident #44. […]

• No harm, potential for more than minimal, patternF759Mar 10, 2022

  Based on observations, interviews, and record reviews, the facility failed to ensure a medication administration error rate of less than 5%. A total of 36 administration opportunities were observed with 10 medication errors for three residents (#57, #443, and #49) of five residents observed for medication administration, resulting in a medication administration error rate of 38.46%. Findings included: 1. A review of Resident #57's Admission Record revealed Resident #57 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident #57's physician's orders revealed an order dated 09/29/2021 for [MEDICATION(S)] tablet, give one tablet by mouth one time a day for constipation. […]