Palm Terrace Healthcare & Rehabilitation Center

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the medical record was accurate for one of eight sampled residents (Resident 1). * Resident 1's progress notes were not accurate. This failure had the potential for the resident's care needs to not be met as their medical information was inaccurate.

Inspectors wroteBased on observation, interview, medical record review, facility document review, facility P&P review, and hospital Encounter Summary review, the facility failed to provide the necessary services and interventions to maintain the highest practicable well-being for one of three sampled residents (Resident 103) reviewed for closed record; and for one of 22 final sampled residents (Resident 10) reviewed for meal observation. * Resident 103 was in his room when LVN (Licensed Vocational Nurse) 8 noted the resident with oral secretions. LVN 8 performed oral suction and then obtained Resident 103's vital signs which included the blood pressure, heart rate, respiratory rate, oxygen saturation (measures the percentage of oxygen-carrying hemoglobin in the blood), and temperature. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure five out of five licensed nurses reviewed for competency had specific competencies and standard of practice skill sets needed to provide safe and efficient nursing care. * The facility failed to ensure LVN 8 had the appropriate competency and skill set to assess and provide interventions when Resident 103 was in critical condition experiencing desaturation (a drop in oxygen levels in the blood), hypothermia (a dangerous, potentially fatal medical emergency where the body loses heat faster than it produces it, causing the core temperature to drop below 95 degrees Fahrenheit), and hypertension (high blood pressure). LVN 8 was unclear of the LVN's scope of practice regarding respiratory care when caring for a resident and failed to call 911 during an emergency. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure six of 22 final sampled residents (Residents 2, 3, 5, 14, 27, and 106) were free from the unnecessary psychotropic medications. * The facility failed to ensure the alprazolam (antianxiety medication) was administered to Resident 2 as per the physician's order. The facility failed to ensure the behavior manifestation was monitored and documented, and the non-pharmacological interventions were provided prior to the administration of the alprazolam medication. * The facility failed to ensure the monitoring of Resident 3's meal intake was accurate to identify when the resident had a meal intake of less than 50% related to the use of mirtazapine (antidepressant medication). [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and were in good condition. * The facility failed to ensure the kitchenware, kitchen utensils, and one heavy-duty blender used for puree preparation were clean and free of food particles or residue. * The facility failed to ensure the cutting boards were kept in a sanitary condition and with cleanable surface. * The facility failed to ensure the hot food and cold beverage were maintained within the acceptable temperature range during tray line. These failures had the potential for cross contamination and foodborne illnesses for the residents consuming the food prepared in the facility's kitchen.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the informed consent was obtained for the use of psychotropic medications for three of five final sampled residents (Residents 4, 5, and 27) reviewed for unnecessary medications. * The facility failed to ensure the informed consent for Seroquel (antipsychotic medication) contained the frequency and route for Resident 4. * The facility failed to ensure the informed consent for alprazolam (antianxiety medication) contained the correct dosage, frequency, and duration for Resident 27. * The facility failed to ensure the informed consent for Xanax (antianxiety medication) was renewed after six months for Resident 5. [...]

Inspectors wroteBased on observation, interview and facility P&P review, the facility failed to provide a homelike environment for one of 22 final sampled residents (Resident 35). * The facility failed to ensure the sound coming from the room air conditioning unit was at an acceptable level for Resident 35. This failure posed the risk for Resident 35 to not have a comfortable place to rest and sleep.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the level 1 PASRR Screening was conducted after a hospital exemption lapsed for one of one resident (Resident 12) reviewed for PASRR. * The facility failed to resubmit a new Level 1 PASRR Screening when Resident 12 had remained in the facility longer than 30 days as recommended in Level 1 PASRR Screening dated 4/30/25. This failure posed the risk for Resident 12 to not receive the necessary mental health evaluation and had the potential for the facility to not incorporate the recommendations from the determination and evaluation report into Resident 12's assessment, care planning, and transition of care.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to develop and implement the comprehensive person-centered care plan for two of 22 final sampled residents (Resident 24 and 53). * The facility failed to develop a comprehensive person-centered care plan for the use of a wander guard for Residents 24. * The facility failed to implement the bilateral floor mats in accordance with Resident 53's risk for falls care plan. These failures posed the risk of not providing the appropriate, consistent, and individualized care to the residents.

Inspectors wroteBased on observation, interview, medical record review and facility P&P review, the facility failed to ensure the comprehensive plan of care was revised to reflect the resident's current care needs and interventions for three of 22 final sampled residents (Residents 4, 19 and 27). * The facility failed to ensure the care plan for pain and use of pain medication was revised to address the use of non-pharmacological interventions prior to the administration of pain medications for Residents 4, 19, and 27. This failure posed the risk of not providing the residents with individualized and person-centered care.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure one of one resident (Resident 53) reviewed for accident hazards remained free from accident hazards. * The facility failed to ensure the bilateral floor mats were provided in accordance with Resident 53's risk for fall plan of care.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the intravenous access for one of two final sampled residents (Resident 105) reviewed for intravenous care. * The facility failed to ensure the PICC line external catheter and arm circumference measurements were completed and documented in Resident 105's medical record upon admission to the facility. This failure had the potential to delay the identification of catheter related complications for the resident.

Inspectors wroteBased on observation, interview, medical record review and facility P&P review, the facility failed to provide the necessary pain management care and services for three of final sampled residents (Residents 4, 19, and 27) reviewed for pain management. * The facility failed to ensure the non-pharmacological interventions were provided to Residents 4, 19, and 27 prior to administering the pain medications. These failures posed the risk for the residents to not receive the appropriate and necessary interventions to manage the residents' pain.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmaceutical services to ensure accurate administration and reconciliation of medications. * The facility failed to ensure LVN 5 flushed Resident 10's GT with 50 ml of water before and after medication administration as per the physician's order. In addition, the facility failed to ensure LVN 5 flushed Resident 10's GT in between medications. * The facility failed to ensure the oxycodone (opioid pain medication to treat moderate to severe pain) removed from the bubble pack was recorded and accounted for in the Narcotic and Hypnotic Record for Resident 109. * The facility failed to ensure the correct medication was administered to Resident 52. [...]

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure two of 22 final sampled residents (Residents 4 and 27) were free from the unnecessary medications. * The facility failed to ensure Residents 4 and 27 were monitored for the signs and symptoms of bleeding related to the use of apixaban medication (anticoagulant medication, use to treat or prevent blood clots). These failures had the potential for the residents to receive unnecessary medications and delay in detecting significant side effects.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 20% * The facility failed to ensure LVN 5 administered the correct dosage of the apixaban (anticoagulant), docusate sodium (stool softener) and sennoside (laxative) medications via GT to Resident 10. The medication cups were observed with significant residue after the medications were administered. * The facility failed to ensure Resident 12 received the voltaren topical gel (topical medication use to relieve pain). * The facility failed to ensure LVN 9 administered the correct dosage of the diclofenac sodium topical medication (medication used to relieve joint pain) for Resident 45. These failures posed the risk for the residents to have potential side effects or complications related to the medications.1. [...]

Inspectors wroteBased on observation, interview, medical record review and facility P&P review, the facility failed to ensure proper storage of medications in one of four medications cart inspected (Medication Cart A). * The facility failed to ensure the ondansetron (antiemetic medication) for Resident 63 who was discharged from the facility was removed from Medication Cart A. This failure had the potential for the medication to be accidentally administered and/or diverted. * The facility failed to ensure the amiodarone (antiarrhythmic medication) and ondansetron medications in the bubble packs for Resident 96 were secured/sealed and free from tears or damage. This failure posed the risk of affecting the potency of the medications, and potential for medications to be diverted. * The facility failed to ensure an opened glargine (long-acting insulin) pen for Resident 108 was dated. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the menus were followed for two of 22 final sampled residents (Residents 14 and 85) * The lunch meal ticket for Resident 14 was not followed when he was served with only one carton of milk. * The facility failed to follow the weekly food menu on 1/29/26 at noon and ensure food preferences and flavor of a boost glucose control were provided to Resident 85. These failures had the potential for the residents not to receive adequate nutrition.

Inspectors wroteBased on observation, interview, facility document review and facility P&P review, the facility failed to ensure food prepared for the residents was cooked to preserve nutritive value. * The vegetables were cooked more than one hour prior to meal service and held in the steam table with a temperature set on high. This failure had the potential to affect the nutritive content of the food and the amount of food residents consume, potentially resulting in a decrease in residents' food intake leading to poor nutrition and health outcomes.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services for one of one final sampled resident (Resident 13) reviewed for hospice services. * The facility failed to ensure the hospice skilled nurse visit notes were available and included in Resident 13's medical records. This failure posed the risk of delay in communication between the hospice provider and facility which may affect resident care.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to implement the infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of diseases and infections. * The facility failed to ensure LVN 5 wore a gown when administering medications via GT for Resident 10 who was on EBP. * The facility failed to ensure Resident 24's call light was disinfected prior to use, when it was on the floor. These failures had the potential for cross-contamination and spread of infectious organisms in the facility.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure one of one glucometer was maintained in a safe operating condition. * The facility failed to ensure the glucometer calibration was performed correctly. In addition, the facility failed to ensure the glucose strip bottle had an open date and the lot number of the glucose strips was documented in the quality control record. Furthermore, the facility failed to ensure the glucose strips and control solutions had an expiration date of 90 days after opening, as per the manufacturer's information. This failure had the potential for residents requiring glucose checks to have inaccurate readings.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the garbage was properly stored in two of seven garbage dumpsters. * Two of seven garbage dumpsters were observed with the lids partially propped open by cardboard boxes, preventing the lids from fully closing. This failure had the potential to attract pest/rodents that carried diseases.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmaceutical services to two of three sampled residents (Residents 1 and 2). * The facility failed to ensure Resident 1's medication was administered timely as ordered by the physician. * The facility failed to ensure Resident 2's medication was administered as ordered by the physician and accurately documented in the MAR. These failures had the potential for the residents to not receive the medications and posed the risk to negatively affect the residents' well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of two final sampled residents (Resident 38 and 587) observed for medication administration were free from the medication errors. * The facility failed to ensure Resident 38's IV medication was dated and documented time of administration. * The facility failed to ensure Resident 587's PIV was dated and labeled. These failures posed the risk for the residents to develop complications related to the IV therapy.

Inspectors wrote2. Medical record review for Resident 28 was initiated on 1/29/24. Resident 28 was readmitted to the facility on [DATE]. Review of Resident 28's Order Summary Report showed a physician's order dated 3/26/24, for continuous oxygen at a rate 2 lpm via nasal cannula. On 1/29/25 at 0851 hours, Resident 28 was observed lying in bed with the supplemental oxygen being administered at a rate of 2 lpm via nasal cannula. On 1/29/25 at 1020 hours, an interview was conducted with LVN 1. LVN 1 stated the oxygen tubing should be changed weekly and as needed. LVN 1 stated the date when it was changed should be written on the tubing. On 1/29/25 at 1219 hours, an interview was conducted with the Central Supply. The Central Supply stated the oxygen tubing was changed every Friday. The Central Supply stated Resident 28's nasal cannula tubing was dated 1/13/25, when she changed out the tubing that morning. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of four residents (nonsampled resident, Resident 736) observed for medication administration was free from the significant medication errors. This failure had the potential to negatively impact the resident's health outcomes.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure eight of eight residents who received pureed food from the kitchen received the proper diets when the facility's puree recipes and menu were not followed as evidenced by: * The facility failed to ensure the puree recipe for potatoes and menu for pureed wheat rolls were followed. This failure had the potential to negatively impact the residents' well-being.

Inspectors wroteBased on observation, interview, facility P&P review, and facility document review, the facility failed to ensure the food safety and sanitary requirements were met in the kitchen. * The facility failed to ensure the food preparation utensils and equipment were in good, sanitary, and cleanable working conditions. * The facility failed to ensure the food items were dated and labeled. * The facility failed to ensure the kitchen staff wore hair restraint. These failures had the potential to cause foodborne illnesses to the medically vulnerable resident population who consumed food prepared in the kitchen.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the baseline care plans were developed to reflect the specific care needs for two of 20 final sampled residents (Residents 686 and 438). * The facility failed to ensure a baseline care plan was developed to address the administration of oxygen for Residents 686 and 438. This failure had the potential for the residents' care needs not being met.

Inspectors wroteBased on interview, facility document review, and facility P&P review, the facility failed to ensure the proper accounting and safeguarding of the controlled medications to prevent loss, diversion, or accidental exposure. * The facility failed to ensure the Narcotic Count Sheet log was signed by the incoming and outgoing licensed nurses assigned to Medication Cart B. This failure posed the risk for loss or diversion of the controlled medications in the facility.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper medication storage. * The facility failed to ensure the open packages of wound care supplies were removed from the medication cart. * The facility failed to ensure the orally used medications were stored separately from the externally used medications. These failures had the potential for medication errors and negatively impact the residents' well-being.

Inspectors wroteBased on interview, medical record review, and the facility's P&P review, the facility failed to ensure the medical records were accurate for one of three residents (Resident 85) reviewed for closed medical records and one of two residents (final sampled resident, Resident 44) investigated for dialysis. * Resident 85's medical record had documentation for the vital signs results and urinary output after his discharge from the facility. * The facility failed to ensure Resident 44's blood pressure access site was accurately documented in the resident's medical record. * The facility failed to ensure Resident 44's blood pressure access site was accurately documented in the resident's medical record. * These failures had the potential for the residents' care needs not being met as their medical information was inaccurate.

Inspectors wroteBased on interview and medical record review the facility failed to ensure one of nine sampled residents (Resident 2) was free from the significant medication errors. * The facility failed to ensure the licensed nurse properly checked and identified the resident prior to administering the medication. This failure had the potential to negatively affect Resident 2's health outcomes.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary pharmacy services were provided to two of two sampled residents (Residents 1 and 2) when the medications were not provided within their prescribed time. This failure had the potential for negative health outcomes for Residents 1 and 2.

Inspectors wroteBased on observation, and interview, the facility failed to ensure resident's meals were served at the desired temperatures. This failure had the potential for the undesirable food temperatures to result in decreased oral meal intake and undesirable weight loss for the residents.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the responsible party and physician for one of 26 sampled residents (Resident 5) were notified when Resident 5 refused to receive the COVID-19 vaccine. This failure resulted in Resident 5's physician and responsible party not being aware of change in the care of Resident 5, which had the potential to negatively affect the resident's well-being. Findings. Medical record review for Resident 5 was initiated on 11/27/23. Resident 5 was admitted to the facility on [DATE]. Review of Resident 5's History and Physical examination dated 10/15/23, showed Resident 5 did not have the capacity to understand and make medical decisions. Review of Residents 5's MDS dated [DATE], showed mild cognitive impairment. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure two of 26 sampled residents (Residents 2 and 4) were monitored every shift for at least 72 hours following the fall incidents. This failure had the potential to not provide the necessary care and services timely for the residents.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the medical records were accurately documented for two of two sampled residents (Residents 1 and 2). * When Resident 1 experienced a fall in the facility, LVN 2 inaccurately documented in the medical record that Resident 1 had no falls, thus placing her as a low risk for falls. * Resident 2's plan of care erroneously showed she experienced an actual fall in the facility. These failures had the potential the residents to not receive appropriate interventions to prevent falls.

Inspectors wroteBased on observation, interviews, facility P&P review, and facility document review, the facility failed to ensure the safe and sanitary food preparation and storage practices in the kitchen as evidenced by: * Fruit flies were observed in the kitchen . * Multiple areas in the kitchen, kitchen equipment, and food storage areas were not cleaned. * The sanitizer red bucket was stored above the clean sheet pans. * Three opened food items (corn kernel, diced carrot, and hot dog) were found in the reach-in freezer. * The dietary staff stored the personal items (drinks) in the kitchen. * Several resident beverages brought in by families were not labeled. These failures had the potential to cause food borne illnesses for the medically vulnerable residents who consumed food prepared in the kitchen.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to maintain an environment free of pests. * Fruit flies were observed on multiple days in the food storage and food production areas. This failure had the potential to cause cross contamination of food and food production surfaces as well as the spread of infections in the facility.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to obtain and maintain a copy of advance directives in the medical records for two of 19 final sampled residents (Residents 21 and 66) and one nonsampled resident (Resident 30). This failure had the potential for the residents' decisions regarding health care and treatment options not being honored.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide an ongoing activity program to meet the needs and interests of two of 19 final sampled residents (Residents 2 and 77). * The facility failed to provide Resident 77 with an individualized activity program which met her identified preference of listening to music. * The facility failed to provide Resident 2 with an individualized activity program which met her identified preference of watching television. These failures had the potential to negatively impact the residents' well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for four of 19 final sampled residents (Residents 10, 21, 66, and 77). * The facility failed to ensure a comprehensive and effective systematic approach was implemented to monitor and maintain acceptable parameters of nutritional status for Resident 10 as evidenced by: - The facility failed to ensure Resident 10 with several unplanned weight loss was monitored effectively as per the facility's P&P and standard of care. - The facility failed to ensure Resident 10's weight goal range was established with the involvement of the resident and/or resident's legal representative, and in accordance with standards of practice. [...]

Inspectors wroteBased on interview and medical record review, the facility failed to provided the necessary care and services for one of 19 final sampled residents (Resident 77) who was on dialysis. * The facility failed to ensure Resident 77's medication was administered as ordered by the physician on the days she was out for dialysis. This failure posed the risk to negatively impact the resident's medical condition.

Inspectors wroteBased on observation and interview, the facility failed to ensure the competency of the licensed nurses in the calibration of medical equipment. * RN 1, and LVNs 1 and 2 were unable to demonstrate competency in the calibration of glucometer (a device to measure BS levels). This failure had the potential to put residents at risk for care not provided in a safe and competent manner.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure safe storage of medications. * The facility failed to ensure Resident 77's medications were not left unattended in the resident's room. This failure had the potential to result in unsafe administration of medications. * Expired medications were observed in one of seven medication carts (Treatment Cart 2). This failure had the potential for the residents to be administered the expired medications.

Inspectors wroteBased on observation, interview, facility P&P review, and facility document review, the facility failed to ensure the menu was followed for two nonsampled residents (Residents 24 and 41). * The facility failed to provide diet gelatin for Residents 41 and 24, both of whom had the physician's orders for CCHO (controlled carbohydrate/diabetic) diets. This failure had the potential for the 22 residents receiving a CCHO diets at risk for nutritionally related health complications.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to follow to provide the appetizing food at appropriate temperatures for three of 19 final sampled residents (Residents 8, 31, and 51) and one nonsampled residents (Resident 23). This failure placed the residents at potential risk for decrease nutritional intake which may affect the resident's overall nutrition status.

Inspectors wroteBased on observation, interview, medical record review and facility P&P review, the facility failed to ensure the medical records were accurate for two of 19 final sampled residents (Residents 10 and 77). * Resident 10 was not provided one on one assistance during meals as ordered by the physician. However, the Medication Administration Record for May 2022 showed one to one feeding assistance was provided. * The facility failed to accurately document Resident 77's fluid intake. These failures posed the risk of the residents not receiving appropriate intervention as the medical record information was not accurate.