Community Care on Palm

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when:1. [NAME] 1 was performing food preparation without a beard restraint and the Dietary Aide had bangs exposed outside the hairnet while working in the kitchen.2. The stovetop was covered with a thick, crusty layer of black and brown grease.3. The interior and exterior surfaces of the oven were coated with heavy, dark buildup, exterior side of the oven door and its handle were coated with thick, heavy residue of old grease and dark deposits, and the bottom part of the oven was coated in a layer of sticky dust and oil residue. These failures had the potential to expose residents who received food from the kitchen to contaminants and could put them at risk of food-borne illnesses.4. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for five of five sampled residents (Residents 36, 53, 41, 21, and 1) on psychotropic (affecting brain activities associated with mental processes and behavior) medications. This failure had the potential for residents or their representatives to not be fully informed of the risks and benefits of psychotropic medications before receiving treatment.

Inspectors wroteBased on observation, interview, and record review, the facility had a medication error rate of 17.14% when six medication errors occurred out of 35 opportunities during the medication administration observation for four out of five residents (Residents 28, 7, 6, and 40). These failures resulted in medications not given according to the physician's orders and had the potential for residents to not receive the full therapeutic effect of medications. These failures also had the potential for blockages to develop in Resident 6's gastrostomy tube (G-tube or feeding tube, a tube inserted through the abdomen that delivers nutrition and medications directly to the stomach).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six residents (Resident 47) was treated with dignity and respect when a Certified Nursing Assistant (CNA 1) stood over the resident while feeding her. This failure had the potential to cause diminished dignity, loss of individuality, and decreased psychosocial well-being during the dining experience for Resident 47.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) was free from unnecessary psychotropic medications (medications that affect brain activities associated with mental processes and behavior) when Resident 1 received an as needed antipsychotic medication (type of psychotropic medication) without physician evaluation. This failure had the potential for Resident 1 to inappropriately receive an as needed antipsychotic medication and had a risk of medication side effects, such as sedation and falls.

Inspectors wroteBased on interview and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS, a resident assessment tool) for two of five sampled residents (Residents 21 and 53). This failure had the potential for Residents 21 and 53 to not receive necessary care or services related to their antipsychotic medications (medications to treat mental illness).

Inspectors wroteBased on interview and record review, the facility failed to ensure an individualized care plan was developed when one of two residents (Resident 32) did not have a care plan for an actual fall. This failure had the potential to result in recurrent falls and serious injury due to lack of interventions to ensure Resident 32's safety following the initial fall event.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate accountability of controlled medications (controlled substances [CS], those with high potential for abuse and addiction) when the Controlled Substance Records (CSR, accountability records) for one of three randomly selected residents (Resident 41) did not reconcile with the Medication Administration Records (MAR, daily documentation record used by a licensed nurse to document medications and treatments given to a resident). This failure resulted in inaccurate accountability of controlled substances and the potential for unidentified discrepancies and possible abuse or diversion of controlled substances.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection prevention and control practices to provide a safe and sanitary environment when a used urinal was found on one of 49 residents (Resident 32)'s bedside table. This deficient practice had the potential to expose residents to infection-causing substances in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food at appropriate temperatures according to the residents' preferences for three out of five sample residents, Residents 3, 4, and 5. This failure had the potential for Residents 3, 4, and 5 to be at risk for decreased nutritional intake which could cause unplanned weight loss and affect their overall nutritional status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a care plan was initiated and/or developed to address the diagnoses of epistaxis (bleeding from the nose) for one of one residents reviewed for quality of care (Resident 1). This failure had the potential for Resident 1 to not be monitored for epistaxis complications and delayed treatment, increasing the risk of further harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two residents reviewed for breathing treatment therapy (Residents 4 and 2), were monitored during and after nebulizer treatments (breathing treatments that turn liquid medicine into a mist). This failure placed the residents at risk for delayed treatment related to possible complications of the nebulizing treatment such as rapid heart rate, restlessness, chest pain and/or difficulty breathing.

Inspectors wroteBased on interview and record review, the facility failed to ensure pharmacy services were provided to meet the needs of the resident when one prescribed medication was not administered as ordered on twelve separate occasions for one of one resident (Resident 23). This failure had the potential to result in ineffective treatment of Resident 23's symptoms and interrupted care.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that dietary staff safely and effectively carried out the functions of food and nutrition services when: 1. Dietary staff, including the dietitian, were not aware of the manufacturer's recommended time guidelines for testing the red bucket Quaternary (Quat) sanitizer (sanitizing solution used for sanitizing food contact surfaces); 2. [NAME] 2 did not demonstrate competency in performing assigned duties; (Cross reference 803) 3. [NAME] 1 did not demonstrate competency in performing assigned duties; and (Cross reference 803) 4. [NAME] 3 did not follow the prescribed recipe when preparing pureed macaroni and cheese during dinner on April 9, 2025. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure: 1. [NAME] 2 followed the recipe when preparing pureed meat and peas during lunch on April 9, 2025; 2. [NAME] 2 used the correct scoop to portion mechanical soft meat during lunch on April 9, 2025; 3. Resident 34, who had a physician-ordered Consistent Carbohydrate (CCHO) diet, was served the correct portion of taco during lunch on April 8, 2025; 4. Resident 3, who had a physician-ordered renal diet, was served appropriate food items during lunch on April 9, 2025, and April 10, 2025; and 5. Resident 33, who had physician-ordered heart healthy diet, was served appropriate food items during lunch on April 9, 2025. These failures had the potential to result in residents receiving food that did not meet their prescribed dietary needs, which could lead to nutrition-related health complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with a prescribed nectar-thick liquid consistency, as ordered by the physician, was served regular thin liquid coffee, for one of nine residents (Resident 8). This failure had the potential to cause resident to choke or aspirate (inhalation of food or liquid into the lungs), placing them at risk for serious health complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. Dust was observed on kitchen equipment and in various locations within the kitchen; 2. An expired sanitizer test strip was found in use. 3. A box of nutritional shake was stored next to defrosting raw meat in the refrigerator; 4. Wilted cilantro was found stored in Reach in Refrigerator # (number) 1; 5. An open bottle of lemonade syrup was stored next to a sanitizer solution bucket; 6. Dust accumulation was oberved on the floor under a table counter; 7. Black grime buildup was observed on the outside of the oven; 8. Three white plastic spatula, two serving tongs handle, and one small spatula had chipped; 9. A trash bag was used as a liner to store a bulk quantity of sugar; and 10. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a comprehensive nutritional assessment was completed within 14 calendar days after admission for one of three residents reviewed (Resident 42). This failure had the potential to delay the provision of resident-centered care (care focusing on the needs of individuals) and nutritional interventions necessary to address the resident's health needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications and biologicals were properly stored and disposed of when expired sterile (entirely free of microorganisms) dressings (medical bandage designed to protect a wound from infection), were found inside a treatment cart and were readily available for use. This failure had the potential to result in residents receiving wound treatments with expired dressings, leading to ineffective treatment and an increased risk of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the therapeutic diet order (diet ordered by a physician) prescribed by the physician was followed for one of three residents (Resident 42) who had an order for a fortified diet (additional nutrients). This failure had the potential for Resident 42 to not receive adequate nutrition, which could further compromise her medical status.

Inspectors wroteBased on interview and record review, the facility failed to ensure, for one of four residents, Resident 1, who was identified as at risk for elopement (a resident leaving the facility unsupervised and unnoticed) and was on line of sight (a resident being within the view of staff members) monitoring was supervised by staff. This failure resulted in Resident 1 eloping from the facility on October 13, 2024, which placed Resident 1 at risk for sustaining serious injury such as being struck by a vehicle or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three residents reviewed (Resident 1) was free from physical abuse when Certified Nursing Assistant (CNA) 1 slapped Resident 1 on the face. This failure had the potential for Resident 1 to suffer physical and emotional injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident ' s right to be free from physical abuse for one out of six residents reviewed (Resident 2), when another resident (Resident 1) hit Resident 2 on the head with a cane. This failure resulted in Resident 2 sustaining four lacerations (deep cut/tear in skin) on his head and bruising to his hands and shoulder. Resident 2 was transferred to the acute hospital, where he received 18 staples (surgical staples - used to close large wounds or deep cuts) to treat his head wounds.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards for one out of six residents reviewed for accidents, when Resident 1 had access to a cane which he used to hit Resident 2. This failure resulted in Resident 2 sustaining four lacerations (deep cut/tear in skin) on his head and bruising to his hands and shoulder. Resident 2 was transferred to the acute hospital, where he received 18 staples (surgical staples - used to close large wounds or deep cuts) to treat his head wounds.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practice was followed when two of three direct patient care staff were observed to wear long and artificial nails. This failure had the potential for the vulnerable residents to be exposed to bacterial cross contamination and the development of infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary conditions were maintained in the kitchen for food storage methods and food sanitation equipment when the ice machine was observed to have a build-up of a slimy pink, yellow and bright green substances where ice is formed. This failure had the potential for contamination, which could result in food borne illnesses for all residents who consume ice from the facility's ice machine. The facility census was 44.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility assessment was reviewed and updated annually and as needed. This failure resulted in an inaccurate evaluation of the facility's population and resources needed to provide the necessary care and services for the residents. During a concurrent interview and record review on March 14, 2024, at 11:02 a.m., with the Administrator (ADM), the ADM stated he was responsible for conducting the facility assessment. The ADM stated the facility assessment should have been reviewed and updated annually. The ADM stated the facility assessment was not reviewed or updated annually. The ADM stated he was not able to initiate the facility assessment. The ADM stated the last facility assessment was on April 18, 2021. [...]

Inspectors wroteBased on interview and record review, the facility failed to initiate and implement their water management program to ensure safe measures in the building's water system. This failure had the potential to increase the risk of the development of Legionella (a specific bacteria that can cause serious type of pneumonia - lung infection) called Legionnaires disease, and other water-borne pathogens in the building's water system which can affect the health and safety of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the lunch menu was followed on February 27, 2024, when residents were served two and a half ounces of chicken instead of three ounces as indicated on the menu for lunch on Monday, March 11, 2024. This failure had the potential for residents' nutritional needs not to be met by being served less than the menu stated portion in accordance with a prescribed regular diet.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure pureed (food blended to a smooth, creamy consistency) food was the appropriate consistency to meet the individual needs of four out of 44 residents (Residents 4, 5, 10 and 25). This failure had the potential for residents on a pureed diet to aspirate (draw food into the lungs) and/or negatively impact the resident's dining experience resulting in poor food intake, compromising their nutritional status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respect and dignity for one of four sampled residents (Resident 4) during mealtime when Certified Nursing Assistant (CNA) 1 was standing over Resident 4 while feeding her. This failure had the potential to negatively affect Resident 4's emotional health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their policy on abuse prevention when Licensed Vocational Nurse (LVN) 1 did not identify, recognize, and believe a resident's allegation that a staff member came to her room and slapped her buttock while changing her diaper, for one resident reviewed (Resident 16). In addition, LVN 1 did not identify Resident 16's allegation as abuse due to the resident's history of reporting false allegations. This failure had the potential for Resident 16 and other residents to not be protected from potential abuse and the allegation not being investigated timely.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's allegation of abuse was immediately reported to the Administrator or State Agency at the mandated time frame (immediately but not later than two hours), when a resident told Licensed Vocational Nurse (LVN) 1, a Certified Nursing Assistant (CNA) slapped her buttock while changing her diaper, for one of one resident reviewed (Resident 16). This failure had the potential to place Resident 16 and other residents' at risk from harm and delayed the investigation of an allegation of abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to initiate a care plan for resident's left lower chin swelling and redness on March 8, 2024, for one of one resident reviewed (Resident 5). This failure had the potential to delay the necessary care and services for Resident 5's left lower chin redness and swelling.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility staff have a current and active Cardio-Pulmonary Resuscitation (CPR - a life-saving procedure used to restart a person's heartbeat and breathing after one or both have stopped) certification, when two of 11 Certified Nursing Assistants (CNA) had expired CPR certification. This failure had the potential for the facility residents not to receive emergency care leading to resident harm and/or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed for two of two residents reviewed (Residents 22 and 42), to ensure: 1. For Resident 22, the licensed staff assessed, notified the physician, and documented when Resident 22 experienced low blood sugar (BS). This failure had the potential for a delay in treatment that could lead to harm and/or death for Resident 22. 2. For Resident 42, followed the regular diet order when Resident 42 received pureed (food blended to a smooth, creamy consistency) bread during lunch on March 13, 2024. This failure resulted in Resident 42's feeling of dissatisfaction with her meals. Findings 1. During an observation on March 13, 2024, at 11:29 a.m., Resident 22 wheeled herself to the nurse's station. Resident 22 asked for her nurse to check her BS. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care and treatment for one of two residents reviewed for oxygen administration (Resident 10), when the physician's order for oxygen administration was not followed. This failure had the potential to result in ineffective oxygen therapy, respiratory distress, and decline in the resident's health condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure for one of 44 residents (Resident 37), the call light was working. This failure had the potential to result in the delay in answering the call light which could affect the delivery of care for Resident 37.

Inspectors wroteBased on interview and record review, the facility failed, for one of three residents reviewed (Resident 1), to provide a written notification to the Office of the State Long Term Care (LTC) Ombudsman, of the plan to transfer a resident to a general acute care hospital (GACH), on December 11, 2023. This failure has the potential for Resident 1 to not have access to an advocate at the Office of the State LTC Ombudsman.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the safety for one of five residents reviewed for falls (Resident 1), when the fall risk care plan was not evaluated for effectiveness and updated to reflect new interventions to prevent further falls, and the fall risk assessments did not accurately reflect Resident 1's fall risk. This facility failure resulted in Resident 1 having repeated falls on November 16, 2023, November 22, 2023, and December 4, 2023. Resident 1 sustained a right radius fracture (broken bone to right arm), laceration (deep cut) requiring sutures to the area above the right eyebrow, and a mildly displaced fracture of adjacent maxillary processes (two missing front teeth) after the second fall on November 22, 2023, which required Resident 1's transfer to the acute care hospital for medical intervention.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure for one of five residents reviewed (Resident 1), to develop and implement care plans with appropriate interventions to address Resident 1 ' s post-fall major injuries. This failure had the potential for a delay in treatment of possible complications related to injuries.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the as needed (PRN) order for Ativan (anti-anxiety medication) for one of three sampled residents (Resident 3) was limited to 14 days. In addition,the facility failed to ensure Resident 3's behavior of anxiety was evaluated and monitored prior to obtaining a PRN Ativan order. This failure has the potential for unnecessary medication use.

Inspectors wroteBased on interview and record review, the facility failed to readmit one of three sampled residents (Resident 1) after hospitalization. This failure had the potential to cause emotional distress to Resident 1 and her responsible person (RP).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure pharmaceutical services were provided to meet the needs for two of seven residents (Resident 1 and Resident 2) when: 1. The routine medication Invega Sustenna (a medication to treat schizophrenia [a mental disorder]) was not available for administration; and 2. The physician order for the administration of Furosemide (a medication to treat fluid retention and swelling) was not followed. These failures had the potential to negatively affect the health and safety of Residents 1 and 2.