Sabal Palms Health & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Sabal Palms Health & Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jun 8, 2022

  Based on observation, resident and staff interview, and record review the facility failed to provide timely care and services for a resident after a reported accident with pain for one resident (#2) out of fourteen sampled residents. Resident #2 reported to nursing staff on 06/24/2022 her right foot had been caught under the wheelchair, while being transported without the foot rests in place, and Resident #2 reported new pain in her right leg. The physician was not notified and no new orders were implemented. On 07/09/2022, Resident #2 was documented to have unrelieved pain in her leg, the physician was notified, an X-ray was ordered which identified an acute fracture of the right proximal tibia. […]

• Actual harm, isolatedF689Jun 8, 2022

  Based on observation, resident and staff interview, and record review the facility failed to provide timely care and services for a resident after a reported accident with pain for one resident (#2) out of fourteen sampled residents. Resident #2 reported to nursing staff on 06/24/2022 her right foot had been caught under the wheelchair, while being transported without the foot rests in place, and Resident #2 reported new pain in her right leg. The physician was not notified and no new orders were implemented. On 07/09/2022, Resident #2 was documented to have unrelieved pain in her leg, the physician was notified, an X-ray was ordered which identified an acute fracture of the right proximal tibia. […]

• No harm, potential for more than minimal, widespreadF921Apr 23, 2024

  Based on observations, interviews, and policy review, the facility failed to ensure clean and sanitary equipment and floors for two of two units and eleven of seventeen rooms where tracheostomy residents reside. Findings included: An observation was conducted on 4/22/24 at 1:14 p.m. in room [ROOM NUMBER] of an oxygen concentrator that had dried liquid splatter on it as well as dust. The suction canister base and motor had debris and dust. There was a fan clipped to a pole at the bedside that was covered in dust. (Photographic evidence obtained.) An observation was conducted on 4/22/24 at 1:18 p.m. in room [ROOM NUMBER] of a IV (Intravenous) pole that had dried splatter on the base. The suction canister and motor set up had dust and debris on it. […]

• No harm, potential for more than minimal, patternF689Sep 23, 2025

  Based on observations, interviews and record reviews the facility failed to ensure the identified needs for residents at high risk for fall interventions was effective and prevented falls with major injuries for two vulnerable residents (#7 and #8) out of eight residents sampled.Findings included:Review of the facility's Daily Census report provided on 9/22/25 at 6:12 a.m. showed 700 Unit had a census of 26.Review of the facility's Minimum Data Set (MDS) Resident Matrix dated 9/23/25 at 8:59 AM showed the 700 Unit 50% (13) of the residents had a fall and 34% (9) experience fall related injuries including fractures. 1. […]

• No harm, potential for more than minimal, patternF695Jul 25, 2024

  Based on observations, interviews, and record review, the facility failed to ensure the positive end-expiratory pressure (PEEP), a pressure applied by the ventilator at the end of each breath to prevent the collapse of the tiny air sacs in the lung, alarm was audible in accordance with professional standards for four residents (#61, #184, #101, and #130) out of thirteen residents requiring mechanical ventilation support. Findings Included: 1. On 7/22/24 at approximately 9:55 a.m. Resident #61 was observed lying in bed with a tracheostomy tube connected to a LTV 1150 mechanical ventilator. A red-letter sign displaying PEEP OFF was observed on the front panel screen. […]