Inspection Report Summary
The most recent inspection on November 16, 2023, identified multiple deficiencies related to resident activities, medication management, skin care, and pest control. Earlier inspections showed similar issues with medication errors, inadequate resident care, and staffing concerns, along with problems in dietary services and infection control. Inspectors cited recurring themes of medication administration errors, failure to follow physician orders for skin conditions, and lapses in resident autonomy and communication. Complaint investigations from prior years included substantiated findings on pressure ulcer care, medication errors, and infection control, but no enforcement actions or fines were listed in the available reports. The pattern of deficiencies has remained relatively consistent over time without clear improvement or worsening.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
8.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
80% worse than Florida average
Florida average: 4.6 deficiencies/year
Deficiencies per year
12
9
6
3
0
Inspection Report
Routine
Deficiencies: 9
Date: Nov 16, 2023
Visit Reason
The inspection was a routine survey of Palm Garden of Tampa nursing home to assess compliance with regulatory requirements related to resident rights, care, medication administration, pest control, and other standards.
Findings
The facility was found deficient in multiple areas including failure to provide access to activities for a resident, failure to support resident self-determination regarding personal refrigerators, failure to inform residents and families of changes in status and medication, unresolved dietary grievances, inadequate treatment and care for skin conditions, failure to reassess bed rail needs, high medication error rate, unsafe medication storage practices, and ineffective pest control program.
Deficiencies (9)
Failed to provide access to activities for one resident (#74), resulting in boredom and anxiety.
Failed to allow two residents (#64 and #62) to exercise autonomy regarding personal refrigerators in their rooms.
Failed to inform residents (#99 and #314) and their representatives of changes in status and medication.
Failed to resolve dietary grievances in a timely manner for two residents (#4 and #85).
Failed to provide treatment and care according to physician orders for non-pressure skin conditions for two residents (#314 and #316).
Failed to reassess the need for appropriate use of bed rails for one resident (#80).
Medication error rate of 24.32% observed during medication administration for two residents (#211 and #25).
Failed to ensure medications were stored safely: unlocked carts, improper storage of refrigerated eye drops, loose tablets, medications left unattended, visitor access to medication carts, and resident self-administering inhaler.
Failed to maintain an effective pest control program as evidenced by presence of gnat-like flies in multiple kitchen areas over multiple days.
Report Facts
Medication administration opportunities observed: 37
Medication errors identified: 9
Medication error rate: 24.32
Residents sampled for bed rails: 3
Residents sampled for medication administration: 4
Residents sampled for grievances: 2
Residents sampled for skin conditions: 2
Residents affected by pest control deficiency: Many
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Licensed Practical Nurse (LPN) | Named in relation to medication administration and treatment deficiencies |
| Staff D | Registered Nurse (RN) | Named in relation to medication administration errors |
| Staff P | Licensed Practical Nurse (LPN) | Named in relation to medication administration errors |
| Staff Q | Licensed Practical Nurse (LPN) | Named in relation to medication cart storage |
| Staff O | Licensed Practical Nurse (LPN) | Named in relation to medication cart storage and bed rail removal |
| Staff H | Licensed Practical Nurse (LPN) | Named in relation to wound care dressing deficiencies |
| Director of Nursing (DON) | Director of Nursing | Named in relation to medication administration, bed rail policy, and wound care |
| Consultant Pharmacist | Consultant Pharmacist | Named in relation to medication administration errors |
| Certified Dietary Manager (CDM) | Certified Dietary Manager | Named in relation to dietary grievances and pest control |
| Assistant Certified Dietary Manager (ACDM) | Assistant Certified Dietary Manager | Named in relation to pest control |
| Life Enrichment Manager | Life Enrichment Manager | Named in relation to resident activity deficiencies and grievance reporting |
| Staff A | Certified Nursing Assistant (CNA) | Named in relation to resident activity deficiencies |
| Staff G | Registered Nurse (RN) | Named in relation to resident activity deficiencies |
| Staff R | Certified Nursing Assistant (CNA) | Named in relation to resident activity deficiencies |
| Staff N | Certified Nursing Assistant (CNA) | Named in relation to personal refrigerator removal |
| Staff K | Certified Nursing Assistant/Unit Clerk/Transport Driver (CNA/UC/TD) | Named in relation to resident family visitation |
Inspection Report
Deficiencies: 1
Date: Nov 16, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with providing appropriate treatment and care according to physician orders for non-pressure related skin conditions for two residents (#314 and #316).
Findings
The facility failed to provide timely and appropriate dressing changes and treatments according to physician orders for two residents, resulting in soiled, undated, and improperly secured dressings. Staff interviews and record reviews confirmed delays in treatment orders and dressing changes, with photographic evidence supporting these findings.
Deficiencies (1)
Failure to provide treatment and care according to physician orders for non-pressure related skin conditions for two residents (#314 and #316).
Report Facts
Residents affected: 2
Treatment dates provided: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Licensed Practical Nurse (LPN) | Confirmed resident #314 did not have treatment orders until 11/13/2023 and stated orders should have been requested at admission |
| Staff H | Licensed Practical Nurse (LPN) | Reviewed photographs of residents' bandages and confirmed dressings should have been changed, secured, and dated |
| Director of Nursing (DON) | Director of Nursing | Reviewed photographs and stated bandages should have been changed and dated according to physician's orders |
Inspection Report
Routine
Deficiencies: 10
Date: Sep 23, 2021
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements related to medication administration, resident care, staffing, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to properly assess and monitor medication self-administration, inadequate accommodation for residents with impaired vision, failure to revise care plans appropriately, improper application of splints, inadequate dialysis care, insufficient nursing staff coverage and response to call lights, failure to monitor psychotropic medication effects, high medication error rates, improper medication storage and labeling, and deficiencies in dietary operations including sanitation and food storage.
Deficiencies (10)
Failure to ensure one resident was assessed for self-administration of medication and medication was not stored at bedside without order.
Failure to reasonably accommodate the needs and preferences of a resident with impaired vision, including assistance at meals and leisure activities.
Failure to revise a care plan to meet the needs related to accommodating impaired vision for one resident.
Failure to ensure treatment and care was provided related to appropriate application of a splint for one resident.
Failure to ensure safe, appropriate dialysis care/services for one resident requiring dialysis.
Failure to provide enough nursing staff every day to meet the needs of every resident and have a licensed nurse in charge on each shift, including timely response to call lights and proper shift change reporting.
Failure to implement gradual dose reductions and monitor target behaviors, side effects, and outcomes for psychotropic medications for two residents.
Medication error rate of 63.8% observed with 23 errors in 36 medication administration opportunities for three residents.
Failure to ensure drugs and biologicals are labeled according to professional principles and stored in locked compartments; narcotics not accounted for and medications not dated when opened.
Failure to procure food from approved sources and maintain kitchen equipment, including undated food items, unclean floor drain, and inaccurate dish machine sanitation logs.
Report Facts
Medication error rate: 63.8
Medication administration opportunities observed: 36
Medication errors identified: 23
Resident weight loss: 6.2
Medication administration time delay: 2.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Licensed Practical Nurse | Administered medications late and did not sign out narcotics properly |
| Staff G | Licensed Practical Nurse | Administered medications late including insulin after meal |
| Staff Y | Certified Nursing Assistant | Applied foot splint incorrectly and unaware of proper use of kick stand |
| Staff W | Physical Therapy Assistant | Reported resident on splint program and educated staff and resident on splint use |
| Staff M | Licensed Practical Nurse/MDS | Interviewed regarding resident with impaired vision and care needs |
| Staff N | Certified Nursing Assistant | Reported resident with impaired vision and missing glasses |
| Staff L | Licensed Practical Nurse/Nurse Supervisor | Interviewed regarding resident with impaired vision and care needs |
| Staff I | Registered Nurse/Infection Control Preventionist | Assisted LPN with medication administration |
| Staff C | Licensed Practical Nurse | Administered medications including crushed potassium chloride |
| Director of Nursing | Director of Nursing | Interviewed regarding staffing, medication administration, and monitoring |
| Pharmacy Clinical Case Manager | Pharmacy Clinical Case Manager | Interviewed regarding medication monitoring and administration policies |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Jan 16, 2020
Visit Reason
The inspection was conducted based on complaints related to failure to provide admission information, advance directive documentation issues, pressure ulcer care, medication administration errors, infection control practices, and catheter care.
Complaint Details
The complaint investigation included issues with admission information, advance directive documentation, pressure ulcer care, medication administration errors, infection control practices, and catheter care.
Findings
The facility failed to provide admission information to a resident and her POA, did not clearly identify advance directive status in medical records for two residents, failed to provide appropriate pressure ulcer care for one resident, had a significant medication error involving insulin administration, and failed to ensure proper infection control practices including hand hygiene, equipment cleaning, and catheter bag maintenance.
Deficiencies (5)
Failed to provide admission information related to facility rules, rates, and resident rights at or after admission for one resident.
Did not ensure advance directive status, related to a DNRO, was clearly identified in the medical record for two residents.
Failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for one resident.
Failed to ensure one resident was free from a significant medication error related to insulin administration.
Failed to ensure appropriate hand hygiene and glove use during medication administration, failed to keep nebulizer and bagged mask off the floor, failed to clean blood pressure cuff between uses, and failed to maintain urinary catheter bag off the floor.
Report Facts
Wound measurement: 2
Blood pressure: 127
Blood pressure pulse: 81
Medication dosage: 2
MDS BIMS score: 7
MDS BIMS score: 13
Urinalysis WBC count: 21
Urinalysis RBC count: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member L | Registered Nurse (RN) | Involved in insulin medication administration error |
| Staff member I | Licensed Practical Nurse (LPN) | Observed performing wound care with improper glove use and hand hygiene |
| Staff member K | Licensed Practical Nurse (LPN) | Observed medication administration and improper infection control practices |
| Staff member J | Licensed Practical Nurse (LPN) | Observed medication administration with improper glove use |
| Staff member F | Licensed Practical Nurse (LPN) | Observed catheter bag on floor and repositioned it |
| Director of Nursing | Director of Nursing (DON) | Provided interviews regarding advance directive and infection control policies |
| Risk Manager | Risk Manager | Provided interview regarding medication error and infection control issues |
| Assistant Director of Clinical Services | ADCS | Provided interview regarding advance directive procedures |
| Social Services Director | SSD | Provided interview regarding advance directive procedures |
| Social Services Assistant | SSA | Provided interview regarding advance directive procedures |
| Staff H | Registered Nurse (RN) | Provided interview regarding admission package procedures |
| Staff C | Licensed Practical Nurse (LPN) | Provided interview regarding advance directive documentation |
| Staff D | Registered Nurse (RN) | Provided interview regarding advance directive documentation |
| Staff E | Registered Nurse (RN) | Provided interview regarding advance directive documentation |
| Director of Guest Services | DGS | Provided interview regarding admission package procedures |
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