Palm Terrace Care Center

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician was notified when the blood sugar (BS) was above 250 mg/dl (milligram/deciliter - unit of measurement) according to the physician's order, for one of three residents reviewed (Resident 3). This failure had the potential for Resident 3's blood sugar to be uncontrolled and could result to complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure wound and care and management for pressure injuries (PI - (localized damage to the skin and underlying tissue, caused by prolonged, intense pressure, friction, or shear forces that cut off blood supply to vulnerable areas, typically over bony prominences like the heels, tailbone, and hips) were provided, for two of three residents reviewed (Residents 1 and 2), when: 1. For Resident 2, there was no complete wound assessment conducted when the resident was readmitted back to the facility; and 2. For Resident 1, there was no complete wound assessment conducted on October 22, 2025. In addition, the wound physician (WP)'s treatment recommendation was not carried out as ordered. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a toileting program was implemented to address bowel and bladder incontinence (involuntary loss of bladder or bowel control), for one of three residents reviewed (Resident 1). In addition, there was no plan of care developed to address Resident 1's bowel and bladder incontinence. This failure had the potential to place Resident 1 at risk for complications such as urinary tract infections, skin breakdown, or kidney damage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an allegation of abuse was reported to the facility abuse coordinator timely according to the facility's policy and procedure, for one of three residents reviewed (Resident A). This failure had a potential for a delay in the implementation of the abuse protocol of investigation and protecting the residents from further abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food safety and sanitation practices were maintained in the kitchen according to standards of practice and facility policy, for 67 out 68 residents who eat food from the kitchen, when: 1. Four (4) large metal pans with food debris and dripping water on them were stored and stacked on top of each other on a bottom shelf; and 2. One 50-pound (lb- unit of measurement) bag of instant milk nonfat dry powder was found stored with an open tear in the bag, with food product seeping out and with clear tape covering it. These failures exposed residents' to contaminated food and unsanitary practices, which had the potential to place them at risk of developing a foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food safety and sanitation practices were maintained in the kitchen according to standards of practice and facility policy, for 67 out of 68 residents who consume food from the kitchen, when pests (a roach, a spider, and ants) were observed in the dry food storage pantry. In addition spiderwebs were also observed inside the kitchen. These failures had the potential to expose residents to contaminated food, that could result in food borne illnesses for all residents who consume food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were answered in a timely manner, for six out 68 residents (Residents 10, 27, 37, 55, 56 and 163). This failure had the potential for the residents' emotional, psycho-social, and optimal physical well-being to not be met.

Inspectors wroteBased on interview and record review, the facility failed to ensure sufficient staff were provided to meet the needs of the residents when the facility did not meet the required or minimum of Actual Total CNA Direct Care Service Hours for CNA DHPPD (DHPPD - measure the numbers of hours of direct care given to residents in skilled nursing facility) of 2.4 hours for March 1, 2025, of 31 days reviewed and April 5, 2025, of 30 days reviewed. The failure to maintain a the required minimum CNA DHPPD hours had the potential to increase the resident's risk of fall and to meet residents' requests for assistance with activities of daily living.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. For Resident 24, facility failed to conduct proper screening for the annual tuberculin skin test (TB- tuberculosis [lung disease] test - screening to determine if someone infected with germs that cause tuberculosis); 2. For Resident 213, one 4,000 milliliters (ml - unit of measurement) incentive spirometer (device use to expand lungs) was observed not properly stored in a bag; and 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident was treated with dignity and respect, for one of six residents reviewed (Resident 215), when the lunch meal was not served to Resident 215 at the same time as the other residents on May 12, 2025. This failure increased the potential to negatively affect Resident 215's psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a comfortable homelike environment, for two of two residents reviewed for environment (Residents 48 and 164), when peeled paint were observed on the wall at the side of Residents 48 and 164's bed and at the bathroom door frame of room [ROOM NUMBER]. These failure had the potential for residents not to experience a comfortable and inviting stay while in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS- a clinical assessment tool) was accurately coded, for one of one resident reviewed for hearing (Resident 214). This failure had the potential to cause inaccuracy in identifying Resident 214's care and support needs, and cause delay of needs being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an audiology (healthcare specialists in hearing loss, hearing tests, hearing aid selection) consultation was provided, for one of one resident reviewed for hearing (Resident 214). This failure had the potential to result in Resident 214 not receiving the audiology services needed to maintain her highest practicable level of well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a dental consultation was provided, for one of one resident reviewed for dental (Resident 24). This failure had the potential to result in Resident 24 not to receive the dental services needed to maintain his highest practicable level of well-being.

Inspectors wroteBased on observation, interview, and record review, facility failed to provide assistive devices such as a plate divider (equipment to prevent food from falling off the plate), for one of three residents observed during mealtime (Resident 22). This failure had the potential for Resident 22 to not meet the daily nutritional needs, which could lead to weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the dietary staff were able to carry out the functions of food and nutrition services safely and effectively when: 1. Food service workers did not follow the facility's cleaning procedure to clean food preparation surfaces and stationary equipment. (Cross referred F 812) This failure had the potential to cause foodborne illness for 64 of 64 sampled residents who received food from the kitchen. 2. [NAME] (CK) 1 served chunky pasta for 10 of 10 sampled residents who had a physician prescribed pureed diet (food that has been ground, pressed and/or strrained to a soft smooth consistency like pudding) during lunch on May 8, 2024. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure medications in emergency medication supply containers (EKITs) were safely stored, with individual medications placed in its own space to distinguish one from others. Two EKITs contained multiple different unit-dose medications in each compartment. This failure had the potential for delay in locating and administering the needed medication, and to increase medication errors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the appropriate food texture was provided for 10 of 10 sampled residents (Resident 6, 11, 13, 32, 39, 62, 63, 219, 170 and 369) who had a physician-prescribed pureed diet (food the has been grounded, pressed and/or starined to a soft smooth consistency like pudding) received chunky noodles during lunch on May 8 2024. This failure had the potential to place the residents at risk of aspiration (accidentally inhaling food or liquid into the lungs), choking, and decreased meal intake.

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. Food service workers did not follow the facility's cleaning procedure to clean food preparation surfaces and stationary equipment. (Cross reference 802); 2. [NAME] (CK) 2 did not cover his mustache; 3. Five cracked tiles were found on the kitchen floor; 4. There was missing grout found in the kitchen dirty area; 5. There was peeling paint and holes found on the wall; 6. Four of four storage shelves in the dry storage room were rusted; 7. There was grease buildup found on the fire hoods; 8. The microwave had buildup; 9. The grid divider was covered with dust in the pot and pans area; 10. The ice machine pipes had buildup; and 11. Seven out of eleven white storage shelves in reach-in refrigerator had chipped paint. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a copy of the Advance Directive (AD - written statement of a person's wishes regarding medical treatment) was available in the resident's record and accessible to staff, for one of three residents reviewed for AD (Residents 15). This failure had the potential to make Resident 15's AD not readily retrievable by the staff and the physician, leaving them unaware of and unable to honor the residents' wishes regarding their medical treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's food preference was honored for one of 64 sampled residents (Resident 39) when milk and soup were not served during lunch on May 7, 2024. This failure had the potential to result in decreased food intake and could lead to unplanned weight loss, further compromising Resident 39's nutritional and medical status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the physician orders were followed for one residnets(Resident 32) during a dinning observation of 15 residents when : 1. Resident 32, who had a Pureed diet (foods the has been ground, pressed and/or strained to a soft smooth consistency like pudding) order received a regular texture salad during lunch on May 7, 2024. 2. Resident 32 received an Oral Nutrition Supplement (ONS- Nutrition drinks that has high calories to help maintain or gain weight) with fewer calories than what the physician had ordered during lunch on May 7, 2024. These failures had the potential to result in choking, aspiration (accidentally inhaling food or liquid into the lungs), and unplanned weight loss, further compromising Resident 32's nutritional and medical status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Treatment Nurse (TN) changed gloves and perform hand hygiene during wound care for one of one resident reviewed for pressure injury (Resident 64). This failure had the potential to result in cross-contaminatin, increasing the spread of infection for Resident 64.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure skin discolorations were identified, addressed, and monitored, according to the facility's policy and procedure, for three of three residents reviewed for skin conditions (Residents 10, 32, and 44) when: 1. Resident 10 was observed to have one dark purple discoloration located on the right inner elbow; 2. Resident 32 was observed to have multiple scattered purple discolorations located on the posterior (back) side of both hands; and 3. Resident 44 was observed to have one linear (straight) purple discoloration located on the back side of the right lower forearm and multiple scattered pink to purple discolorations located from the left elbow to the left hand. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure kitchen utensils were clean and in safe operating conditions. This failure had the potential to result in cross contamination and foodborne illness (stomach illness acquired from ingesting contaminated food) in a medically vulnerable population of 66 residents who consumed food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the humidifier was changed according to their facility policy, for one of one resident reviewed for oxygen (Resident 35). This failure had the potential for Resident 35 to have a humidifier which was not working properly and may result in the decline of Resident 35's respiratory status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pharmacy services provided to the residents met their needs when: 1. One medication was attempted to be administered to one resident (Resident 160), that was labeled with another resident's name; 2. The facility along with the Consultant Pharmacist (CP) did not develop and implement policy and procedures for safe use of compounded sterile preparations (CSPs - preparing medication in an environment free from bacteria, viruses, or any other potentially infectious microorganisms) that included education and competency assessment of the facility nursing staff related to intravenous (IV - into the vein) compounding; and 3. [...]