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Inspection visit

Inspection

BLUE PALMS HEALTH AND REHABILITATION CENTER AT FLECMS #1053516 citations on this visit
6 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 6 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to adhere to their grievance policy for one resident (#26) of 43 sampled residents. Findings included: An interview with Resident #26 on 11/02/21 at 10:40 a.m. revealed the facility was short staffed to the point where he was left to sit in his own bowel movement for 4 hours. He reported this happened two nights ago (Sunday 10/31/21), when they were short staffed and he used his call light and no one responded on the 3:00 p.m. -11:00 p.m. shift. He reported it wasn't until 1:00 a.m. when a temporary staff person came into his room and assisted him. He reported that he reported this to the nurse, who ended up quitting that same day. Review of Resident #26's medical record revealed he was admitted to the facility on [DATE] with a diagnosis that included hemiplegia and hemiparesis following cerebral infraction affecting left dominant side. Review of the resident's Brief Interview For Mental Status (BIMS) dated 8/12/21 revealed a score of 15 (cognitively intact). Review of the facility's Grievance Log from September 1, 2021, to November 2, 2021 revealed no entries related to Resident #26. An interview on 11/02/21 at 1:30 p.m. with Staff F, Social Worker (SW), revealed that she has presented all grievances filed by a resident or on behalf of a resident on the grievance logs provided. She reported that she was not aware of any other grievances. An interview on 11/04/21 at 11:10 a.m. with Staff E, Registered Nurse (RN) revealed that she was familiar with Resident #26 and was typically assigned to him. She reported her first day back on shift was Tuesday and the resident told her that the night prior he had a bowel movement and no one changed him. She reported that at that time the night nurse Staff O, RN was still on the unit and they both went into the room to discuss the issue with the resident. The resident was unable to confirm what he previously reported. She reported that she did not report the resident's complaints to anyone other than the night nurse and that she did not document the resident's concerns. An interview on 11/04/21 at 11:20 a.m. with Staff F, SW revealed that if a resident makes a complaint to anyone a grievance should be written. She reported the nurse who the resident made the complaint too should have written up a grievance form. She reported the grievance forms can be found outside the SW office on both the first and second floor. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 15 Event ID: 105351 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave Tampa, FL 33613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview on 11/04/21 at 11:58 a.m. with Staff F, revealed that she just spoke to Staff E, RN who reported that when the resident made the complaint, she and the night shift nurse went into the resident's room and the resident was clean and dry at that time so the concern was resolved, and did not need to be reported as a grievance. Staff F reported that if someone complains of something and it is addressed right away then it is not considered a grievance. She reported that she was unsure if the resident felt the issue was resolved and reported the Certified Nursing Assistant (CNA) assigned to the resident for the time period in question was not interviewed. An interview on 11/04/21 at 12:02 p.m. with the Director of Case Management, RN, revealed that at the time when the concern was reported the nurses involved checked to make sure the resident was clean, and checked the resident's skin with no concerns noted. She reported that there is no documentation from the nurses that a report was made, no documentation of care provided and no documentation of a skin assessment. Review of the facility policy titled, Grievances, Resident, with a revised date of 11/2016 revealed the following: The facility will do its best to respond to the resident's issue/concern within 24 hours after a thorough investigation is conducted. The resident (or resident representative) will receive notification of the outcome. The grievance/Complaint Report form should be completed by the appropriate department head that initially received the complaint and then forwarded to the Administrator for review and appropriate action. All resident grievances will be recorded on the Grievance/Complaint Log, which will be updated and maintained by the Administrative Assistant to the Administrator. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 2 of 15 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave Tampa, FL 33613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. An interview on 11/03/21 at 1:30 p.m. with a group of five alert and oriented residents (#25, #34, #69, #75, #87) revealed that none of the five residents were invited to their care plan meetings. An interview on 11/05/21 at 11:37 a.m. with Staff F, Social Worker revealed that care plan meetings are currently being done via a phone conference. She reported that alert and oriented residents' invitations are hand delivered to the resident and family/representatives get their invitations mailed to them. She reported the receptionist keeps a binder of those invitations that are sent out and hand delivered. An interview on 11/05/21 at 1:32 p.m. with Staff F, revealed that invitations are not put in the resident's chart. She reported that she knows the receptionist sends out the invitations and the invitations for alert and oriented residents are hand delivered to the resident in the facility, but she had no documentation that would confirm the five alert and oriented residents, who were present at the meeting, received an invitation. Based on observations, record reviews, and interviews the facility failed to ensure, six residents (#25, #34, #69, #75, #87 and #99) and a representative for one resident (#40) were invited and/or participated in their plan of care meetings out a total of 43 sampled residents. Findings included: The policy, Resident/Family Participation in Goal Planning, revised 11/2016, indicated, To assure the residents and resident representative's right to participate in planning the resident's care in making informed decisions regarding medical treatment. The procedure identified the following: - 1. A resident has the right to participate in the development and implementation of his or her person-centered plan of care, including requirements that affect both the initial planning process and changes to the plan of care. - 3. Residents and their families or other resident representatives will be given the opportunity to attend an interdisciplinary goal planning conference to participate in resident care planning and medical treatment decision making. - 4. Before the goal planning conference, the Social Worker will invite residents who are able to comprehend their care plan to attend the meetings which are scheduled for them. If a resident chooses not to attend a conference the Social Worker inquires if there are nay care issues the resident wants addressed by staff. - 5. Resident and resident representative attendance at the goal planning conference will be noted in the resident's medical records. Staff F, Social Worker, stated on 11/5/21 at 11:36 p.m. the protocol for care plan meetings was for the family members to attend via phone conference. She stated that alert and oriented residents were invited and brought to the meeting. The Social Worker identified the receptionist sends out invites to families and the invitations are hand delivered to the residents. The staff member indicated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 3 of 15 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave Tampa, FL 33613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some that attendees of the meetings are family, resident, and the interdisciplinary team, which included the long-term dietary technician, social services, whatever nurse was available, and activities. 1. Resident #87's admission Record indicated the resident was admitted on [DATE] and diagnoses included Type 2 Diabetes Mellitus without complications and essential hypertension. The admission Record identified the resident as being the resident representative. The annual Minimum Data Set (MDS), dated [DATE], indicated the resident scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicative of an intact cognition. An interview was conducted, on 11/2/21 at 10:45 a.m., with Resident #87. The resident thought the facility had only one care plan meeting since his admission. The Care Plan Meeting form, dated 10/6 and 10/7/21, indicated that it was the annual meeting and the attendees included Staff F, Social Worker, the Dietary Technician, and a registered nurse. The form indicated that on 10/7/21 a phone conference was conducted with the resident's family member. The meeting form did not indicate the resident had attended the meeting on either date. Staff F confirmed, on 11/5/21 at 1:49 p.m., that Resident #87 was alert and oriented to person, place and time and should have been invited to the care plan meeting. She stated she did not know if an invitation had been given to the resident. The Nursing Home Administrator asked the SW, during the interview, if the receptionist (who sends out care plan invitations) had sent her an email to reschedule the meeting and the SW informed her no. 2. A review of Resident #99's admission Record indicated the resident was admitted on [DATE] and had diagnoses that included unspecified encephalopathy and unspecified dementia without behavioral disturbance. The quarterly MDS, dated [DATE], indicated the resident had a BIMS score of 15, indicating intact cognition. During an interview Resident #99 stated, on 11/2/21 at 11:07 a.m., no not invited (to care plan meeting) they treat us like sick people. A review of the Care Plan Meeting form, dated 10/20/21, indicated the only attendees included Staff F, Social Worker and the Dietary Technician. The review of the clinical notes for Resident #99 indicated that on 10/20/21 the resident's [family member] had attended the care plan meeting on 10/20/21. On 11/5/21 at 12:11 p.m., Staff F, Social Worker stated that Resident #99 was alert and oriented and would be invited. She stated the [family member] of the resident does attend the care plan meetings. Staff F stated she knew the resident had been invited but refused, saying that the [family member] would be attending. The staff member reviewed the care plan meeting form that was used during the meeting and stated it was used as a sign-in sheet and she would make a note of who attended. She reviewed the care plan meeting and confirmed that nursing had not been involved and stated that nursing does attend when they are available. Staff F stated, on 11/5/21 at 1:35 p.m., the receptionist had the invitations that had been sent out and it included a phone number the family was to call to schedule the meeting. She stated she did not speak with Resident #99 regarding the 10/20/21 meeting. She stated the [family member] had attended a care plan meeting that was done after the facility had held their meeting. Staff F reviewed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 4 of 15 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave Tampa, FL 33613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the Care Plan form and identified the check marked areas were for information that may be addressed during the meeting. 3. The electronic medical record indicated Resident #40 was admitted on [DATE] with diagnoses that included metabolic encephalopathy and vascular dementia without behavioral disturbance. The quarterly Minimum Data Set (MDS), dated [DATE], indicated the BIMS assessment was not conducted as the resident was rarely/never understood. On 11/4/21 at 4:42 p.m., the spouse of Resident #40 was sitting at bedside. The spouse stated he had not been invited to a care plan meeting, but they said they were going to implement that. Staff F stated, on 11/5/21 at 12:24 p.m., that since the resident had moved to the long-term care side of the facility and the spouse had not attended any care plan meeting. She stated she was not involved in the skilled residents' care plans. Staff F, Social Worker stated that a care plan meeting had not occurred as planned on 9/8/21 and the Administrator had just spoken with the resident's spouse. She stated that due to her being on vacation the week of 9/8/21 the meeting had not occurred and that another one would have to be scheduled. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 5 of 15 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave Tampa, FL 33613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview the facility failed to provide for dependent residents appropriate nail care for one resident (#13) of 43 sampled residents. Residents Affected - Few Findings included: Observations on 11/02/21 at 11:54 a.m. of Resident #13 revealed the resident lying in his bed. It was noted that the resident had a contracture to his right hand with his nails elongated approximately half an inch past the top of his finger. Observations on 11/04/21 at 10:48 a.m. revealed the resident lying in bed with his eyes open. The resident was noted with a contracture to his right hand with his nails on the right hand elongated and approximately half an inch past the top of his finger. An interview on 11/04/21 at 10:58 a.m. with Staff H, Licensed Practical Nurse (LPN), revealed that the CNAs do nail care which would include cutting the resident nails whenever necessary. She reported the aides are to check and cut resident nails if needed on the resident's shower days. At this time Staff H checked a white erase board at the nurses station and indicated that the resident's shower days were Mondays and Thursdays on the 3:00 p.m. -11:00 p.m. shift. An observation on 11/04/21 at 11:01 a.m. of the resident's hand with Staff H, LPN present, she confirmed that the resident's nails on his right hand were too long. Staff H, reported that she will have his nails cut right away. Review of the Minimum Data Set (MDS) dated [DATE] indicated the resident has long and short term memory problems, and severely impaired cognitive skills for decision making. For personal hygiene the resident is total dependence of 1 person physical assist and for bathing the resident is total dependence of 1 person physical assist. Review of the facility policy titled Bath, Shower, with a revised date of 5/2015 revealed the following: 8. Give special care to umbilicus, folds of skin, hands and feet. 12. Care of fingernails is part of the bath. Be certain nails are clean. Rinse off skin and dry thoroughly. Review of the facility policy titled Bath, Bed, with a revised date of 5/2015 revealed the following: 10. Give special care to umbilicus, folds of skin, hands and feet. 14. Care of fingernails is part of the bath. Be certain nails are washed. Review of the Minimum Data Set (MDS) dated [DATE] indicated that the resident has long and short term memory problems, and severely impaired cognitive skills for decision making. For personal hygiene the resident is total dependence of 1 person physical assist and for bathing the resident is total (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 6 of 15 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave Tampa, FL 33613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0677 dependence of 1 person physical assist. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Bath, Shower with a revised date of 5/2015 revealed the following: 8. Give special care to umbilicus, folds of skin, hands and feet. Residents Affected - Few 12. Care of fingernails is part of the bath. Be certain nails are clean. Rinse off skin and dry thoroughly. Review of the facility policy titled Bath, Bed with a revised date of 5/2015 revealed the following: 10. Give special care to umbilicus, folds of skin, hands and feet. 14. Care of fingernails is part of the bath. Be certain nails are washed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 7 of 15 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave Tampa, FL 33613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interview, the facility did not ensure that pharmacy recommendations were followed for one resident (#41) out of 5 residents sampled for unnecessary medications, related to the change in dosage for Aspirin from 325 mg (milligrams) to 81 mg recommended by the consultant pharmacist on 08/03/21. Residents Affected - Few Findings included: Review of Resident #41's consultant pharmacist's medication regimen review (MRR) revealed the resident had a recommendation dated 08/03/21 to reduce the resident's aspirin dosage from 325 mg to 81 mg to avoid increased risk of bleeding. In an interview with the Director of Nursing (DON) on 11/04/21 on 8:55 a.m. she said that she had only been in her position since 10/01/21 and was not the DON when the recommendation was made. She said she didn't realize the recommendations hadn't been done before 11/03/21, so she did them at that time. A review of the admission Record revealed Resident #41 was admitted to the facility on [DATE] for diagnoses that included sepsis, presence of cardiac pacemaker, and embolism and thrombosis of unspecified artery. The resident had a physician order for Aspirin 325 mg to give one time daily related to embolism and thrombosis of unspecified artery dated 10/01/21 and discontinued on 11/03/21. The resident also had a physician order for Aspirin 81 mg to give 1 tablet by mouth one time a day for pain dated 11/03/21. The resident's medication administration record reflected the order set. In an additional interview with the DON on 11/04/21 at 11:00 a.m., she said that she thinks Aspirin will default to a pain diagnosis within the system, and she would have to go back into the electronic system and change it. On 11/05/21 at 12:34 p.m. in a telephone interview with the Consultant Pharmacist for the facility, it was her expectation that pharmacy recommendations to be worked on throughout the month, but the facility would hopefully have them done within 30 days, before she came back to the facility to complete the next monthly review. When asked if she felt recommendations from August 3rd (2021) should be addressed prior to November 3rd, she said that she would absolutely hope so. In a policy titled, Medication Monitoring Medication Regimen Review and Reporting, dated 09/18 under Procedures, #8 read, Recommendations shall be acted upon within 30 calendar days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 8 of 15 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave Tampa, FL 33613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review, the facility failed to ensure the medication error rate was less than 5.00%. Twenty-nine medication administration opportunities were observed and six errors were identified for five (#21, #20, #85, #25, and #37) of five residents observed. These errors constituted a 20.69% medication error rate. Residents Affected - Few Findings included: 1. On 11/3/21 at 4:32 p.m., an observation of medication administration with Staff A, Registered Nurse (RN) and Staff I, Licensed Practical Nurse (LPN), was conducted with Resident #21. Staff A was observed administering the following medications: - Eliquis 5 milligram (mg) oral tablet - Carvedilol 25 mg oral tablet - Gabapentin 300 mg oral capsule - Timolol Maleate 0.5% eye drops - Novolog 100 unit/milliliter (u/mL) FlexPen 2 units injected. During the oral administration of medication Staff A obtained a blood glucose level of 186 from Resident #21. The observation continued as Staff A removed a Novolog 100 unit/milliliter (u/mL) from the medication cart. The staff member dialed the dosage selector to 2 units and Staff I instructed Staff A to prime the pen by emptying the insulin into the trash. Staff A held the insulin pen with the needle pointing downwards over the carts trash container and the insulin was emptied into the trash. Staff A dialed the dosage selector to 2 units, entered the residents room and injected the insulin into the residents left upper extremity. On 11/3/21 at 4:58 p.m., Staff A and Staff I confirmed that the Novolog FlexPen had been primed over the trash while holding the pen with the needle facing downward. Staff A confirmed that she had primed the Flexpen into the garbage and had primed the pen while holding the pen upside down, with the needle pointing into the trash. According to https://www.novo-pi.com/novolog.pdf, to avoid injecting air and to ensure proper dosing users should turn the dosage to 2 units, while holding the Novolog FlexPen with the needle up, tap the cartridge a few times to make any air bubbles collect at the top, and while keeping the needle pointing upwards press the push button to the dose selector reads 0. The facility policy, Medication Administration - Subcutaneous Insulin, dated 2007, instructed users to Always perform the safety test before each injection. The policy indicated that by performing the safety test ensured that the pen and needle were working properly and removed air bubbles. The procedure instructed users to hold the pen with the needle pointing upwards, tap the insulin reservoir so that any air bubbles rise up towards the needle, press the injection button all the way in, and to check if insulin comes out of the needle tip. On 11/3/21 at 5:03 p.m., the Director of Nursing (DON) was informed of the procedure that Staff A (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 9 of 15 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave Tampa, FL 33613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and Staff I used to prime the Novolog FlexPen, she did not acknowledge if the pen should be primed while holding the needle up. 2. On 11/3/21 at 4:48 p.m., an observation of medication administration with Staff A, Registered Nurse (RN) and Staff I, Licensed Practical Nurse (LPN), was conducted with Resident #20. Staff A was observed administering the following medications: - Carvedilol 12.5 mg oral tablet - Senna Plus 50 mg/8.6 mg oral tablet. A review of the Physician's orders for Resident #20 revealed the following medication order: - Senna 8.6 mg tablet (Sennosides) - Give 8.6 mg by mouth two times a day for constipation. The review of the Medication Administration Record indicated Staff A had administered the 5:00 p.m. dose of 8.6 mg Senna. The facility policy, Medication Administration - General Guidelines, dated 2007, indicated that Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medications. The policy instructed staff to: - Prior to administration, review, and confirm medication orders for each individual resident on the Medication Administration Record. Compare the medication and dosage schedule on the resident's MAR with the medication label. - Medications are administered in accordance with written orders of the prescriber. - Verify medication is correct three (3) times before administering medication. -- a. when pulling medication package from med cart. -- b. when dose is prepared -- c. before dose is administered. 3. On 11/4/21 at 9:15 a.m., an observation of medication administration with Staff E, Registered Nurse (RN), was conducted with Resident #85. Staff E was observed administering the following medications: - Ascorbic Acid 500 mg - Multi Vitamin with mineral tablet - Vitamin D3 50 microgram (mcg) tablet - Diltiazem 60 mg - 2 tablets (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 10 of 15 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave Tampa, FL 33613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0759 - Zinc Sulfate 220 mg capsule Level of Harm - Minimal harm or potential for actual harm - Megestrol 20 mg tablet - Memantine Extended Release (ER) 28 mg capsule Residents Affected - Few Staff E confirmed that 8 oral tablets/capsules had been dispensed, then she crushed the tablets, opened the oral capsules, and mixed the medications in pudding. The observation revealed the resident pushed the vanilla pudding further onto the spoon, which the staff member threw into the trash along with the medication cup. She confirmed that she probably could have used the rim of the medication cup to administer the rest of the pudding. She stated that the resident had probably not received the ordered dosages of the medications. A review of the Medication Administration Record (MAR) for Resident #85 revealed the above observed medications were scheduled to be administered and in addition to: - Donepezil Hydrochloride (HCl) 10 mg tablet orally The observation of medication administration with Staff E and the confirmation by the staff member of the number of dispensed medications indicated Donepezil had not been administered. 4. On 11/4/21 at 9:31 a.m., an observation of medication administration with Staff H, LPN, was conducted with Resident #25. Staff H was observed administering the following medications: - Aspirin Enteric Coated (EC) 81 mg tablet - Active Liquid Protein - Clopidogrel Bisulfate 75 mg tablet - Entresto 24-26 mg tablet - Furosemide 40 mg tablet - Metoprolol Succinate Extended Release (ER) 25 mg tablet - Multi Vitamin with mineral tablet - Trelegy Ellipta 100 microgram (mcg)/62.5 mcg/25 mcg inhaler. A review of the Order Summary Report for Resident #25 indicated that the physician ordered a MultiVitamin tablet one time a day. The order did not identify that staff should administer a Multi Vitamin with minerals. 5. On 11/4/21 at 9:52 a.m., an observation of medication administration with Staff J, LPN, was conducted with Resident #37. Staff J was observed administering the following medications: - Clopidogrel 75 mg tablet (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 11 of 15 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave Tampa, FL 33613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0759 - Divaloproex Delayed Release (DR) 250 mg tablet Level of Harm - Minimal harm or potential for actual harm - Ferrous Sulfate 325 mg tablet - Simethicone 80 mg tablet Residents Affected - Few - Misoprostol 200 mcg tablet - Multi Vitamin with mineral tablet - Sulfamethoxazole - trimethoprim (tmp) DS tablet. Staff J confirmed seven tablets had been dispensed. After entering Resident #37's room, Staff J asked the provider, who was standing at bedside, if the facility could get an order for over-the-counter Acidophillus instead of the Florastor ordered as the facility was having an issue with obtaining the medication from the pharmacy. A review of the Medication Administration Record (MAR) indicated that an order for Acidophilus two times a day for Probiotic, started 11/4/21. The MAR identified that Acidophilus was not administered as scheduled on 9 a.m. on 11/4/21 and that a Probiotic capsule (Saccharomyces boulardii) scheduled to be administered at 9 a.m. on 11/4/21 was not administered. The MAR indicated that Resident #37 was not administered the 9 a.m. dosage of 25 mg of Metoprolol Tartrate. The physician order did not include parameters to hold the medication. Staff J documented a blood pressure of 111/55 but did not identify that the physician was notified by the nurse that the Metoprolol was not administered. An interview was conducted at 11:14 a.m. on 11/5/21 with the Director of Nursing (DON). She stated her expectation was that medications be given as ordered. The DON stated she understood that insulin pens should be held upright during priming of the pen, and that doctors (providers) should be notified if a medication was being held due to a blood pressure and if there were no parameters. She reviewed the orders for Resident #37 and confirmed that if the probiotic was available to be given on other days it should have been available. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 12 of 15 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave Tampa, FL 33613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a safe and homelike environment related to wall baseboard bumpers, handrails, and a resident wall being in disrepair were reported to maintenance staff within a timely manner for repair on one floor (first floor) of two floors . Findings included: An initial tour of the facility on 11/02/2021 at 12:15 p.m. revealed various locations throughout the facility's first-floor hallways with the wall baseboard bumpers, located approximately one foot from the ground, detaching and sticking out from the wall. During these observations handrails were observed throughout the first-floor hallways in disrepair with the internal metal exposed. (Photographic Evidence Obtained) These locations and observations included: 1. The wall bottom bumper located on the right side of room [ROOM NUMBER]. 2. The wall bottom bumper located on the right side of room [ROOM NUMBER] next to room [ROOM NUMBER]. 3. The handrail on the left side of room [ROOM NUMBER]. 4. The wall baseboard bumper on the left side of room [ROOM NUMBER]. 5. The wall baseboard bumper in-between rooms [ROOM NUMBERS]. 6. The endcap connection point of the handrails, located on the corners of the hallways, across from room [ROOM NUMBER] and on the left side of room [ROOM NUMBER]. 7. The endcaps of the handrails, located on the corners of the hallways, across from room [ROOM NUMBER] and on the side of room [ROOM NUMBER] across from room [ROOM NUMBER]. 8. The endcap connection point of the handrail located on the wall corner on the right side of the clean utility room next to room [ROOM NUMBER]. 9. The handrail on the left side of room [ROOM NUMBER]. 10. An observation inside room [ROOM NUMBER] of the A- bed wall, right side of the room, revealed the wall with scratches and grime build-up when A-bed was in the lowest position. An interview on 11/04/21 at 11:05 a.m. with Staff B, Certified Nursing Assistant (CNA) revealed if staff observe any maintenance or environmental disrepairs a work order slip much be filled out and placed into the maintenance work order box. Staff B, CNA stated if any issues or concerns are observed throughout her work assignment, then a work slip should be immediately filled out to, make sure it doesn't get too bad. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 13 of 15 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave Tampa, FL 33613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0921 Level of Harm - Minimal harm or potential for actual harm An interview on 11/05/21 at 9:15 a.m. with the Maintenance Director revealed should staff observed equipment or environmental conditions in disrepair, the first method to report the disrepair is to the receptionist so a work order slip can be completed and input into the online maintenance system. The Maintenance Director stated the work orders are reviewed and anything that are a safety issue are prioritized. Residents Affected - Some Record review of maintenance open and completed work orders dated from 10/01/2021 to 11/05/2021 revealed no work orders for repair related to handrails, wall baseboard bumpers, or the wall in room [ROOM NUMBER]. A tour with the Maintenance Director on 11/05/21 at 9:48 a.m. confirmed the wall bumpers located approximately one foot from the ground and handrails listed above being in disrepair. An observation inside of room [ROOM NUMBER] confirmed the wall by A-bed on the right side of the room with scratches and grime. The Maintenance Director stated the expectation is that anyone who sees equipment in disrepair should be reporting it to ensure it is repaired within a timely manner. Housekeeping is the first line of defense for observing equipment in disrepair, such as the handrails and baseboards, as they are walking the entire facility. The Maintenance Director confirmed that it is the expectation for the wall bumpers, handrails, and walls to be reported to the maintenance department for repair. An interview on 11/05/21 at 1:19 p.m. with the Nursing Home Administrator (NHA) revealed the expectation is that when facility equipment disrepairs are seen, a work order is completed for it to be reported to the maintenance staff for repair. The NHA confirmed that a wall baseboard bumper detaching or sticking out from the wall could result in a resident sustaining a skin tear, or, if the handrails are not fully secured and a resident is using them for mobility it would result in an incident. A review of the Maintenance Procedures, not dated, revealed, . The DOF [Director of Facilities] shall be responsible for managing the Maintenance Service Program (Name of System) in accordance with these policies . The ADOF [Assistant Director of Facilities] shall be responsible for coordinating work on site by (Name of System) and/or building staff, including . properly completing all work orders based on maintenance requests received from residents or originated by staff . requesting DOF to assign work orders to (Name of System) for timely forwarding of work orders to the staff . arranging legal access to all occupied units as necessary for outside contractors or maintenance personnel . inspecting completed work and notifying DOF of any issues or problems . The MS [Maintenance Staff] shall be responsible for . scheduling maintenance work . accomplishing all work in a timely and professional manner and as director by the DOF . maintenance of all tools and equipment, including identification and security measures . SECTION 1.0 Maintenance and Repairs 1.1 REPAIRS . The front desk will then input the request into the (Name of System) system for maintenance personnel assignment. The (Name of System) request should provide enough information to authorize staff and/or vendors . Response by Maintenance: It shall be the goal of maintenance to respond to non-emergency work (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105351 If continuation sheet Page 14 of 15 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105351 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Blue Palms Health and Rehabilitation Center at Fle 4100 E Fletcher Ave Tampa, FL 33613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete orders within 48 hours and complete the repair within 5 days of request by a resident. Upon receipt of a properly completely work order the DOF or ADOF shall prioritize and schedule the work. Emergency work orders will be responsible to immediately or within 24 hours. . The DOF and/or Housekeeping Manager . shall be responsible for maintaining all building common areas in a clean and orderly condition . Event ID: Facility ID: 105351 If continuation sheet Page 15 of 15

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Citations

6 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0677GeneralS&S Dpotential for harm

    F677 - A resident who is unable to carry out activities of daily living receives

    Provide care and assistance to perform activities of daily living for any resident who is unable.

  • 0757GeneralS&S Dpotential for harm

    F757 - Unnecessary Drugs—General

    Ensure each resident’s drug regimen must be free from unnecessary drugs.

  • 0585GeneralS&S Dpotential for harm

    F585 - Grievances

    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

  • 0656GeneralS&S Epotential for harm

    F656 - Comprehensive Care Plans

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  • 0759GeneralS&S Dpotential for harm

    F759 - Medication Errors

    Ensure medication error rates are not 5 percent or greater.

  • 0921GeneralS&S Epotential for harm

    F921 - Other Environmental Conditions

    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

FAQ · About this visit

Common questions about this visit

What happened during the November 5, 2021 survey of BLUE PALMS HEALTH AND REHABILITATION CENTER AT FLE?

This was a inspection survey of BLUE PALMS HEALTH AND REHABILITATION CENTER AT FLE on November 5, 2021. The surveyor cited 6 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at BLUE PALMS HEALTH AND REHABILITATION CENTER AT FLE on November 5, 2021?

Yes, 6 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide care and assistance to perform activities of daily living for any resident who is unable."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.