Health inspection·September 17, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, review of administrative records and interview, the facility failed to ensure that the facility's vents, other equipment, and areas were maintained, as evidenced by the appearance of multiple air vents having Black colored substances or rust-like staining on them; several ceiling tile and surfaces surrounding the vents having notable water staining around them; and sink cabinets with an offensive odor, black colored and water staining in them.The findings included:A tour of the facility was conducted on 09/17/25 beginning at 10:00 AM revealed multiple air vents with black colored substances or rust-like staining on them and several ceiling tile and surfaces surrounding the vents had notable water stains around them throughout the therapy area and on the Reflection Hallway.In the general therapy area, there was an air vent upon entry into the therapy area, as follows: 2 of three front vents outside the door; and 1 of 2 back vents in the therapy gym had noted black colored substance visible on them. In the general therapy room, there was a hand washing sink and below the sink was a cabinet. Upon opening the cabinet, there was an immediate noticeable offensive musty, moldy smell emitting from the cabinet. Further observation of the cabinet noted black colored substances in the bottom of the cabinet and water stains and cobwebs on the inside bottom side of the cabinet. The restroom in the therapy area also had an air vent with a black colored substance on it. In the Occupational Therapy side of the therapy area, there were several vents in this area which had black colored substances on them. In the Speech Therapy office, the air vent and around the sprinkler head, there was noted water stains on the ceiling and dark colored substances on them. In the Physical Therapy charting room, there was a vent with black colored substance on it.In the Rehabilitation (Rehab) Director's office, the air vent had rust-like staining on it. In the entrance to the Reflection Hallway, there was a large water staining on the ceiling. At the Reflection Nursing Station, the vent was noted to have rust-like spots on it.(Picture evidence available) A random interview with a resident receiving therapy was conducted on 09/17/25 at approximately 1:50 PM. The resident voluntarily said that she noticed that the vents needed to be cleaned. An interview was conducted with one of the therapy staff, Staff A, on 09/17/25 in the morning, revealed that the staff has experienced multiple respiratory illnesses in the last few months and was informed that it was from environmental issues. The staff also expressed that the air quality in the therapy room smells musty and moldy at times, especially when the air conditioner has been off. The staff expressed that the therapy gym air vents have black colored substances on them as well as in some of the smaller rooms in the therapy area. The staff was unaware if any testing for mold had been done but expressed that he/she has been experiencing respiratory issues lately. An interview with another therapy staff, Staff B, on 09/17/25 in the afternoon, expressed they have experienced respiratory illness in the last few months and have noticed the discoloration of the air vents in the therapy area. The staff expressed that they are wearing mask more now. An interview was conducted with the Rehab Director on 09/17/25 at 10:15 AM, who stated Page 1 of 2 105592 105592 09/17/2025 Palm Garden of Vero Beach 1755 37th Street Vero Beach, FL 32960

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few that he had noticed the black colored substances around the vents and that he reported this in the electronic system designated for maintenance. He stated they came that same day. He denied being aware of any staff experiencing respiratory issues. An interview was conducted on 09/17/25 at 10:50 AM with the Maintenance Director, who stated the facility is in the process of having a new roof put on and stated there is debris and dust coming down. He denied having testing done on the black colored substances visualized on the air vents. He stated that housekeeping will dust the vents, but the maintenance staff need to take down the vents and clean on the inside. He stated the facility conducts routine vent checks. The surveyor requested copies of the checks. Review of the Monthly AC [Air Conditioner] Vent Cleaning & Dusting Checklist documented the weekly checks. The Checklist noted instructions which is included:*Clean and dust all vents listed below once each week.*Initial in the correct box for each week ending date.*Report damaged, loose, or excessively dirty vents to Maintenance Supervisor. Review of the Monthly vent checklist sheets documented the facility has checked that the weekly checks were completed. Review of the September checks revealed that the staff documented that they have performed the weekly checks for week 1 and week 2 and noted the areas completed included Nursing Stations, Therapy Gym, and Hallway/Common Area Vents.Interview with the Maintenance Director on 09/17/25 in the afternoon, revealed the checks are done on Wednesdays, thus the check for week 2 would have been completed on 9/12/25. However, the surveyor conducted an observation on 09/17/25 and noted the above disparities, 5 days after the facility allegedly conducted the checks and had cleaned the vents. An interview was conducted on 09/17/25 at 11:25 AM with the Reflections Unit Manager, who expressed that there was a leak on the 100-wing, it was reported, and maintenance fixed the leak the same day. It should be noted that the above noted large water damage on the ceiling is from the Reflection Hallway. Review of the maintenance log revealed the following:A 05/16/25 - Work Order # 16784, which documented the PT gym under sink looks like termite pellets and mold. The maintenance staff documented that this was completed on 05/17/25 at 9:11 AM. There is no notation of what was found or done. It should be noted that during the surveyor's tour on 09/17/25, the above noted condition of the cabinet beneath the sink remained the same.A 06/23/25 work order # 17144, which documented, please paint the areas around our duct areas in the gym? Black spots/Stains. Both therapy gyms.' The work order documented a close-out date on 06/23/25 at 1:30 PM. It should be noted that the during the tour on 09/17/25, the conditions remained. 105592 Page 2 of 2