Inspection·September 11, 2020

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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** Based on observation, interview and record review, the facility failed to implement a care plan intervention related to fall prevention as written and determined by the facility's Interdisciplinary Team for one resident (#59) of four residents that required floor mats. Findings included: Record review of the Incident by Incident Type Log for March 9, 2020 to September 9, 2020 revealed Resident #59 had seven falls since April 2020. Four out of the seven falls were classified as unwitnessed. The unwitnessed falls occurred on 4/29/20, 5/2/20, 6/27/20, and 9/8/20. An observation on 9/9/20 at 2:54 p.m., revealed Resident #59 was lying in bed under the covers. His bed was in the lowest position with the handrails lifted. There were no floor mats observed on the floor beside the Resident's bed. Further observation revealed no floor mat availability within the room. Resident #59's admission Record revealed an admission date of 1/18/20 with medical diagnoses to include heart failure, major depressive disorder, repeated falls, weakness, history of falling. Resident #59's Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status of 5 that indicated severe impairment. The MDS Section G: Functional Status revealed Resident #59 required extensive assistance with one-person physical assist for bed mobility, transfer, and toilet use. Record review of Resident #59's active care plan revealed an initiated focus, dated 1/19/20, for, At risk for further falls related to: Decreased lower extremity strength, History of multiple falls, Poor safety awareness, Unsteady gait/balance, fatigue, sob [shortness of breath] with exertion, antidepressant. Interventions included ensuring appropriate footwear (initiated on 2/10/20), scheduled toileting every 2 hours while awake (initiated on 6/29/20) and ensuring floor mats are at bedside while in bed (initiated on 4/28/20). Progress Notes: Incident Note, dated 9/8/20, revealed, Started morning rounding at 7:10AM and heard resident's roommate calling out. Came to see resident laying on the floor. Asked resident what happened and he said I fell. After asking resident what happened, resident was assessed. Vital signs taken . Placed resident back in bed with assistance by other staff nurse. Denies pain . An interview was conducted on 09/09/20 at 3:10 p.m. and Staff A, Certified Nursing Assistant (CNA) stated that Resident #59 recently had a fall on 09/08/20 and the facility was going to re-evaluate Resident #59 for additional interventions, including possibly requiring floor mats while the resident (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 5 Event ID: 105574 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 105574 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Garden of Largo 10500 Starkey Rd Largo, FL 33777 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)