Palm Valley Post Acute

Inspectors wroteBased on clinical record review, staff interviews, and facility documents and policy, the facility failed to ensure electronic medical records remained confidential for one resident (Resident #159). The universe was 163. The deficient practice could result in violations of patient privacy.

Inspectors wroteBased on the clinical record review, interviews, and facility policy, the facility failed to ensure that a Preadmission Screening and Resident Review Screening was completed for 1 of 4 residents (Resident #158). The universe was 163. The deficient practice could result in specialized services not being identified and provided to the residents.

Inspectors wroteBased on observation, staff interviews, and policy and procedures, the facility failed to ensure that refuse was disposed of appropriately. The deficient practice could result in an unsanitary condition and/or the harborage of pests.

Inspectors wroteBased on the observations, clinical record review, interviews, and facility policy, the facility failed to ensure that urinary catheter bag for 1 of 2 sampled residents (Resident #6) was not resting on the floor. The universe was 22. The deficient practice could lead to catheter associated infection due to inappropriate urinary catheter bag placement. Findings Include:Resident #6 was admitted on [DATE], with diagnoses of sequelae of cerebral infarction, chronic respiratory failure, acute pulmonary edema, type 2 diabetes mellitus, and immunodeficiency. The care plan dated November 19, 2025, had a focused care area for Indwelling Catheter: Neurogenic Bladder. [...]

Inspectors wroteBased on observations, staff interviews, record review, and policy review, the facility failed to ensure the medication error rate was not 5% or greater, by failing to administer medications as ordered for two of four residents (#139, #87). The deficient practice could result in adverse effects and further medication errors.

Inspectors wroteBased on observation, staff interviews, and review of facility policy, the facility failed to ensure that there were no expired supplies readily available for resident use and that medications available for resident use had visible expiration dates. The deficient practice could result in an increased risk for side effects or ineffective drug therapy. The census was 172 and the sample consisted of 34 residents.

Inspectors wroteBased on clinical record reviews, staff interviews, review of facility documentation and policy, and observation of current practice, the facility failed to evaluate and implement effective care plan interventions related to falls for one of two sampled residents (#156). The deficient practice resulted in the resident experiencing multiple falls in the facility, and could result in other residents failing to receive effective fall-prevention measures. The census was 172.

Inspectors wroteBased on interviews, review of records, and review of facility policy and procedure, the facility failed to protect the rights of one of five sampled residents (#1) to be free from abuse by another resident (#3). The deficient practice could lead to ongoing abuse leading to harm of other residents.

Inspectors wroteBased on clinical record review, staff and resident interviews, facility documentation and policy review, the facility failed to confirm that an allegation of misappropriation was appropriately reported to the state agency (SA). Failing to report could lead to other residents property being misappropriated.

Inspectors wroteBased on closed clinical record review, staff interviews, facility documentation and policy review, the facility failed to implement adequate supervision to one resident (#3) which resulted in a fall with injury. The deficient practice could result in other injuries to residents.

Inspectors wroteBased on clinical record review, observation, interviews, and the facility policy and procedures, the facility failed to ensure that the physician and resident representative were notified of missed and rescheduled dialysis treatments for three of 10 sampled residents (#3, #9, #19); failed to ensure that pre and/or post dialysis assessment(s) were completed for resident (#18); and, failed to ensure dialysis policy contained the minimum requirements for the provision of dialysis services according to professional standards. The deficient practice could result in dialysis treatments and care not being met and not safely administered.

Inspectors wroteBased on clinical record review, observation, interviews, and the facility policy and procedures, the facility failed to protect the rights of one resident (#63) to be free from physical abuse by another resident (#48). The deficient practice could result in residents being physically injured.

Inspectors wroteBased on clinical record review, resident and staff interviews, facility documentation and policy review, the facility failed to ensure the necessary treatment and services were provided for 3 of 32 sampled residents according to professional standards regarding following physician orders for two residents (#95 and #77) and behavior monitoring for one resident (#108). The deficient practice resulted in resident hospitalization and could result in residents not receiving the necessary treatment, services and monitoring they need.

Inspectors wroteBased on observations, interviews, clinical record review, and review of facility policy, the facility failed to ensure pressure ulcer was assessed, monitored and treatment was provided for one sampled resident (#95). The deficient practice could result in development and/or worsening pressure ulcers.

Inspectors wroteBased on review of resident council minutes, resident and staff interviews, and facility policy and procedures, the facility was failed to ensure concerns from the resident council meeting were considered or acted upon by facility staff. The facility census was 161 and the sample size was 32. The deficient practice could result in the residents' concerns, views, grievances or recommendations that affect their care, treatment and quality of life are not valued and considered.

Inspectors wrote-Resident #38 was admitted on [DATE] with diagnoses of major depressive disorder-single episode, anxiety disorder and schizoaffective disorder. The care plan dated December 14, 2021 included that the resident used an antidepressant medication related to depression and an antipsychotic medication related to schizoaffective disorder bipolar type. Interventions included to administer medications as ordered and psych follow-up as needed. The Level I PASRR (Pre-admission Screening and Resident Review) dated December 19, 2023 revealed that the resident had SMI (serious mental illness) diagnoses that included major depression and bipolar disorder; had mental disorder (MD) diagnoses of anxiety disorder.; and had no primary diagnosis of dementia. [...]

Inspectors wrote-Resident #153 was admitted on [DATE] with diagnoses of encephalopathy, type II diabetes mellitus, and acute pulmonary edema. A respiratory note dated December 9, 2024 revealed that resident was on 2 liters per minute of oxygen via nasal cannula. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 15, indicating intact cognition. The MDS assessment also coded that the resident was receiving oxygen therapy. A nurse practitioner (NP) note dated January 24, 2025 revealed the resident was on oxygen via nasal cannula. An observation was conducted on February 3, 2025 at 11:30 a.m. showing that resident #153 lying in bed wearing an oxygen nasal cannula that was connected to an oxygen concentrator by the bedside. The oxygen concentrator was on and set to 3 liters of oxygen. [...]

Inspectors wroteBased on observation, clinical record review, facility documentation and staff interviews, the facility failed to ensure medications/treatment for two residents (#316 and #93) were not left at bedside. The facility census was 161 and the sample size was 32. The deficient practice could result in resident injury, medication over-dose or contraindications.

Inspectors wroteBased on observations, clinical record reviews, resident and staff interviews and policy review, the facility failed to ensure respiratory care related to BiPAP (Bi-level positive airway pressure)/CPAP (Continuous positive airway pressure) devices for one of 3 sampled residents (#98) and oxygen administration for one of 3 sampled residents (#153) consistent with professional standards was provided as ordered by the physician. The deficient practice could result in residents not receiving the necessary respiratory care and services to meet their needs.

Inspectors wroteBased on review of resident council minutes, resident and staff interviews, a food test tray, and policy review, the facility failed to ensure food was palatable; and, failed to ensure food was at an appetizing temperature for resident consumption. The facility census was 161 and the sample size was 32. The deficient practice has the potential for residents who disliked a meal to experience nutritional problems or dissatisfaction with their meals.

Inspectors wroteBased on observations, staff interview, and policy review, the facility failed to ensure food items were labeled and dated; failed to ensure temperature logs were maintained; and, failed to ensure kitchen was clean when preparing food for resident. The deficient practice could increase the risk of foodborne illness.

Inspectors wrote-A medication administration observation was conducted with licensed practical nurse (LPN/staff #221) on February 4, 2025 at 9:05 a.m. The LPN entered a resident's room with prepared medications. There was an EBP (enhanced barrier precaution) signs posted outside of the resident's room. The LPN sanitized her hands, donned gloves on, mixed the crushed medications with water in separate medication cups, paused and disconnected the residents tube feeding, flushed the tube feeding with water and then administered the medications one at a time through the feeding tube. The LPN then flushed the feeding tube with water, reconnected and resumed the tube feeding then took her gloves off and sanitized her hands. However, the LPN did not don a gown prior to administering the medications to the resident. An interview was conducted on February 4. 2025 at 9:29 a.m. [...]

Inspectors wroteBased on observations, clinical record review, resident and staff interviews, and review of facility policy, the facility failed to protect and value the resident's private space by staff failing to knock on doors and requesting permission before entering rooms of two residents (#69 and #66); and, failed to ensure staff explained the care/treatment prior to performing ADL (activities of daily living) care for to one resident (#69). The deficient practice could result in residents' individuality not respected and residents not being treated in a dignified manner.

Inspectors wroteBased on observations, clinical record review, staff interviews, and review of facility policy and procedures, the facility failed to ensure call light within reach for one sampled resident (#466). The deficient practice could result in residents not having their needs met timely which could negatively impact resident safety.

Inspectors wroteBased on clinical record review, staff interviews, facility documentation, policies and procedures, the facility failed to protect the rights of one resident (#4) to be free from physical abuse by another resident. The deficient practice could result in further abuse of residents and appropriate action not taken.

Inspectors wroteBased on observations, clinical record reviews, staff interviews and policy and procedures, the facility failed to ensure that mitt restraints were removed following physician orders for 2 of 2 sampled residents (#69 and #133). The deficient practice could result in a lack of re-evaluation for the ongoing safe use of these restraints placing residents at risk for possible injury.

Inspectors wroteBased on staff interviews, review of facility documentation, policy and procedures the facility failed to implement their policy to protect one resident (#4) from abuse and failed to thoroughly investigate an allegation of abuse for one resident (#4). The deficient practice could result in abuse continuing and not being prevented.

Inspectors wroteBased on clinical record review,staff interviews and review of facility documentation and policy/procedure, the facility failed to ensure an allegation of abuse was thoroughly investigated. The deficient practice could result in allegations of abuse not being investigated and abuse/neglect occurring in the facility.

Inspectors wroteBased on clinical record review, staff interviews, and policy review the facility failed to ensure one of 3 sampled residents (#77) and/or resident representative was provided with written notice regarding the bed hold policy upon transfer to the hospital. The deficient practice could result in residents and/or resident representatives not being informed of the facility's bed hold policy and not permitted to return to the facility. Findings Include: Resident #77 was re-admitted on [DATE] with diagnoses of type 2 diabetes, end stage renal disease (ESRD), atherosclerosis of arteries, peripheral vascular disease and congestive heart failure. The information provided in the resident's admission packet revealed no evidence that the bed hold policy was provided to the resident and/or the resident representative. [...]

Inspectors wroteBased on observation, clinical record review, resident and staff interviews and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure that the Minimum Data Set (MDS) assessment for one of 32 sampled residents (#98) was accurate. The deficient practice could result suboptimal care planning and resident not receiving the care/services according to their needs.

Inspectors wroteBased on observation, clinical record review, resident and staff interviews, and facility policy review, the facility failed to ensure that a baseline care plan was developed and implemented regarding the use of BIPAP (Bilevel Positive Airway Pressure)/CPAP (continuous positive airway pressure) care/treatment within 48 hours for one of three sampled residents (#98). The deficient practice could result in lack of instructions for the provision of effective and person-centered care to the resident and staff not being aware of the equipment being used.

Inspectors wroteBased on clinical record review, observations, staff interviews and facility policy, the facility failed to ensure that an individualized on-going program of activities that met the interests and supported the well-being were consistently provided for 1 of 1 sampled residents (#69). The deficient practice could result in resident's interests, the physical, mental and psychosocial well-being, decreased socialization and stimulation not being met. Findings Include: Resident #69 was admitted on [DATE] with diagnoses of anoxic brain damage, hydrocephalus, altered mental status, seizures, quadriplegia, deformity of head, psychosis, depression, and anxiety disorder. [...]

Inspectors wroteBased on observation, staff interviews, and facility policy, the facility failed to ensure that medications were not left unattended on top of the medication cart. The deficient practice could result in residents having access to unnecessary medications. The facility census was 161 and there were 32 sampled residents.

Inspectors wroteBased on clinical record review, staff interviews, and the facility policy and procedures, the facility failed to ensure a thorough investigation for one abuse allegation out of three on a resident to resident abuse complaint, involving resident #88 and #77. The deficient practice could result in appropriate corrective action not taken and an inaccurate investigative outcome.

Inspectors wroteBased on documentation, staff interviews and the facility policy and procedures, the facility failed to ensure that one resident (#2) was free from abuse from another resident (#12). This deficient practice could result in other residents being abused.

Inspectors wroteBased on clinical record reviews, staff and resident interviews, facility documentation and policies, the facility failed to ensure that one resident (#1) was free from abuse by another resident (#2).

Inspectors wroteBased on clinical record reviews, staff interviews, facility documentation, policies and procedures, the facility failed to protect resident rights (#4002) to be free from sexual abuse by another resident (#4805). The deficient practice has the potential for further abuse resulting in harm to residents.

Inspectors wroteBased on clinical record review, staff and family interviews, and review of facility policy and documentation, the facility failed to ensure personal privacy and confidentiality of medical records were maintained for one resident (#604). The deficient practice could result in unauthorized disclosure of resident information.

Inspectors wroteBased on clinical record review, staff interviews, facility documentation and policy and procedure review, the facility failed to protect the rights of one residents (#79) to be free from sexual abuse by another resident (#252); and, failed to protect the rights of one resident (#33) from physical abuse by another residents (#354 and #356). The deficient practice could result in further abuse of residents to occur.

Inspectors wrote-Resident (#65) was admitted on [DATE] with diagnoses of rhabdomyolysis, ESRD (end-stage renal disease and chronic peripheral venous insufficiency. The eINTERACT summary dated December 24, 2023 included the resident had a change in condition: abnormal vital signs, altered mental status and shortness of breath. Review of the clinical record revealed the resident was transferred to the hospital on December 24, 2024 for diagnoses of influenza and pneumonia. Further review of the clinical record revealed that the resident was readmitted back to the facility on December 28, 2024 into a private room for isolation due to Influenza A diagnosis. However, continued review of the clinical record revealed no evidence that the resident/ representative was notified in writing of the reason of the transfer. There was no documentation that the Ombudsman was notified of the resident's transfer/discharge. [...]

Inspectors wrote1) Based on clinical record review, interviews, and facility documentation and policy, the facility failed to ensure that nine out of 18 residents were free from abuse. The deficient practice resulted in physical and/or emotional injury to the residents. Resident #143 is a [AGE] year-old male admitted on [DATE] with admitting diagnosis of urinary tract, infection, end-stage, renal disease, heart failure, rhabdomyolysis, and altered mental status. Resident brief interview for mental status is 15 out of 15 as of [DATE]. Based on the facility ' s five day report, a complaint by the resident was received by the dialysis facility social worker reporting that one of his certified nursing assistants (CNA) was mean to him and grabbed him, roughly and caused bruises on his left arm. [...]

Inspectors wroteBased on clinical record review, interviews, and facility documentation and policy, the facility failed to follow its policy regarding reporting and investigating abuse. The sample size was four out of 18 residents. During the investigation conducted on 12/18/2023 through 12/22/2023, revealed documentation that the suspicion of abuse was not reported immediately to the administrator and to other officials according to state law. The policy states the term, immediately, as meaning within two hours of an allegation of abuse involving or resulting in seriously bodily injury or within 24 hours of an allegation that does not involve abuse resulting in serious bodily injury. The policy documents that any employee who has been accused of resident abuse is to be placed on leave with no resident contact until an investigation is complete. [...]

Inspectors wroteBased on clinical record review, interviews, and facility documentation and policy, the facility failed to ensure that one resident ' s rights were protected by failing to report an accident and injury. Resident #168 is a [AGE] year old male admitted on [DATE] with the admitting diagnosis of dementia, chronic obstructive pulmonary disease, Parkinson ' s disease, acute kidney failure, and history of COVID-19. SBAR evaluation dated [DATE], reveals that resident had a fall that sustained a hematoma to his head. A progress note dated [DATE] at 4:59 PM, a Night Shift CNA was interviewed and he reports that the resident fell at around 5:45 AM on the morning of [DATE], just prior to the morning shift. The resident was up in his wheelchair and was found on floor next to the wheelchair near patio door. [...]

Inspectors wroteBased on observations, clinical record reviews, resident and staff interviews, and facility documentation, policy and procedures, the facility failed to ensure that allegations of sexual abuse for one resident (#38) were reported immediately to the State Agency (SA) as required. The deficient practice resulted in resident subjected to further sexual abuse and could result in protection of other residents being compromised and increased risks for serious injury and harm. As a result, the Condition of Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified.

Inspectors wroteBased on observations, clinical record reviews, resident and staff interviews, and facility documentation, policy and procedures, the facility failed to ensure that allegations of sexual abuse for one resident (#38) was thoroughly investigated. The deficient practice could result in protection of residents being compromised, residents are placed at increased risks for serious injury/harm and further abuse and appropriate corrective action not taken. As a result, the Condition of Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified.

Inspectors wroteBased on observations, clinical record review, resident and staff interviews, review of facility documentation, policy and procedures the facility failed to ensure one resident (#38) was free from sexual abuse from staff. The deficient practice resulted in psychosocial harm to resident #38 and had placed residents at increased risk for further abuse, serious injury, harm and psychosocial harm. As a result, the condition of Immediate Jeopardy (IJ) and Substandard Quality of Care (SOC) were identified. The census was 164.

Inspectors wroteBased on clinical record reviews, staff interviews, facility documentation and review of policies and procedures, the facility failed to implement their policy regarding protection of resident, reporting and investigating an allegation of sexual abuse for one resident (#38). The deficient practice resulted in appropriate corrective action not taken, further sexual abuse for resident #38, compromised protection of other residents, abuse not reported and thoroughly investigated.

Inspectors wroteBased on documentation, staff interviews, and the facility policy and procedures, the facility failed to report an allegation of sexual abuse to the stated agency, and failed to complete a 5-day written investigation. The deficient practice could result in residents not being protected from abuse.