Palm Village Retirement Comm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store medications in two of three medication carts when: 1. Medication cart, referred to as, 900-WB, contained three expired prescription medications for two residents (Resident 59 and Resident 90). 2. Medication cart, referred to as, 300-600, contained one expired prescription medication for one resident (Resident 11) and one expired over-the-counter medication. This failure had the potential to decrease medication potency that could compromise the therapeutic effectiveness of stored medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure kitchen staff used appropriate portioning utensils for food service, which is necessary to provide accurate and consistent meal portions to residents (Resident 12), when one staff member was observed using a regular metal teaspoon instead of standardized portioning utensil to serve cottage cheese during meal preparation. This failure had the potential to result in inconsistent portion sizes and negatively impact residents' nutritional intake and dietary orders.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food was stored, prepared and distributed in accordance with professional standards when:1. Four kitchen staff (KS) employees (KS 4,5,6 and 7) and the Certified Dietary Manager (CDM) were observed working in the kitchen without wearing beard nets, despite having facial hair.2. Reach in refrigerator was not maintained at 40 degrees Fahrenheit (a way to measure temperature) or below.3. Clean souffle bowls were stored with visible food crumbs and debris on them.4. The stove had visible grease and grime on its surface and behind the unit. The adjacent wire rack, which held bottles of cooking oils and vinegars, had visible grease and food spillage on both the bottles and shelving.5. The chute of the East Wing ice machine, where ice is dispensed, was observed to be soiled with an orange and black substance. [...]

Inspectors wroteBased on observation, and interview, the facility failed to provide residents with accessibility to file anonymous grievances or complaints and did not update the grievance policy to ensure the prompt resolution of grievances for three out of 12 sampled residents (Resident 41, Resident 100, and Resident 112) when:1. Resident 41, Resident 100, and Resident 112 did not know how to file a grievance anonymously.2. The facility's policy and procedure (P&P) titled Palm Village Health Care Center Grievances Policy was not updated to ensure the residents were informed of their right to submit grievances anonymously. This failure placed residents at risk of deterrence from reporting concerns, limited access to grievance resolution, and infringement upon their rights to concerns without fear of identification or reprisal.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Minimum Data Set Assessment (MDS- MDS-assessment of physical and psychological functions and needs) accurately reflected resident's health and functional status for three of eight sampled residents (Resident 1, Resident 10, and Resident 73) when: 1. Resident 1's fall and surgery was inaccurately coded in MDS assessment. This failure had the potential to result in Resident care needs not met and the potential for additional fall and injury. 2. Resident 10's restraints were inaccurately coded in the quarterly MDS assessment. This failure had the potential to result in incorrect treatments provided to Resident 10 due to inaccurate assessments.3. Resident 73's restraints were inaccurately coded in the quarterly MDS assessment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive resident-centered care plan for two of five sample residents (Resident 60 and Resident 1) when:1. Resident 60's care plans did not include the physician prescribed oxygen (O2- a colorless, odorless and tasteless gas essential for life) therapy. This failure had the potential for Resident 60 to experience shortness of breath, respiratory distress, decrease oxygen saturation, confusion, loss of consciousness and respiratory failure (a condition where there is not enough oxygen or too much carbon dioxide in your body).2. Resident 1 did not have a care plan developed for anticoagulant (medication used to prevent blood clots) use, Physical Therapy (PT) and Occupational therapy (OT) treatments. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards of quality for five of fourteen sampled residents (Resident 60, Resident 87, Resident 32, Resident 2 and Resident 79) when:1. The Licensed nurse (LN) did not accurately assess and document Resident 60's change in skin condition on the weekly assessment. This failure had the potential for Resident 60 to experience worsening skin conditions, declining health status, hospitalization and or death.2. Resident 87 did not receive oxygen (O2- a colorless, odorless and tasteless gas essential for life) therapy as ordered by the physician on 7/1/25. This failure placed Resident 87 at risk for experiencing shortness of breath (SOB) and respiratory distress (difficulty breathing).3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent when the facility's medication error rate was 12 percent. There were 25 opportunities for errors and three medication errors occurred for three of thirteen sampled residents (Resident 26, Resident 65 and Resident 79) when:1. Resident 26 was administered a chewable aspirin tablet with oral medications and swallowed whole.2. Resident 65 was administered a chewable aspirin tablet with oral medications and swallowed whole.3. Resident 79 was administered pain medication prescribed for severe pain, despite reporting moderate pain. These failures resulted in the incorrect administration of medication which could lead to a reduction of medication effectiveness, under medication or overmedication and negative outcomes.

Inspectors wroteBased on observation, interview and record review, the facility failed to observe infection control measures for two of seven sampled residents (Resident 60 and Resident 79) when:1. The Licensed Vocational Nurse (LVN) did not perform hand hygiene after disposing of soiled wound dressing during Resident 60's wound dressing change observation. This failure had the potential to result in cross contamination (bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) and transmission of infection between residents, staff and visitors.2. There was no storage bag for Resident 60's nasal cannula (NC- a tube that directs oxygen into the nose). This failure had the potential to result in Resident 60 becoming infected with a virus or bacteria from contaminated (having been made impure by exposure to a substance) oxygen tubing.3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that maintained dignity and respect for one of three sampled residents (Resident 8) when Resident 8's urinary catheter (flexible tube inserted into bladder to drain urine) bag was uncovered and visible to other residents and visitors. This failure had the potential to compromise Resident 8's dignity and privacy by exposing their foley catheter bag, leading to embarrassment or psychosocial harm. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a new Preadmission screening and Resident Review (PASARR- a federal requirement to ensure residents with mental disorder or intellectual disorder or intellectual disabilities are not inappropriately placed in a nursing home) level 1 screening for one of five sampled residents (Resident 2) when Resident 2's PASARR level 1 dated 5/14/25 completed prior to admission to the facility did not include diagnosis of anxiety (mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with daily activities) and use of psychotropic medications (drugs that affect the mind, emotions, and behavior). This failure had the potential for Resident 2 to not receive the appropriate services related to her diagnosis and medication used.

Inspectors wroteBased on interviews and record review, the facility failed twice to complete a level 1 Preadmission Screening and Resident Review (PASARR), (a Federal requirement to ensure residents with mental disorder or intellectual disorder or intellectual disabilities are not inappropriately placed in a nursing home) screening notifying the state mental health authority or state intellectual disability authority promptly after a significant change for one of three sampled residents (Resident 4). This failure had the potential for Resident 4 to not receive the appropriate services related to her mental disorder.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of eleven sampled residents' (Resident 12 and Resident 79) drug regimen was free from unnecessary drugs when: Resident 79 received acetaminophen-codeine (opioid and nonopioid combination prescription medication used to treat pain) tablet prescribed for severe pain, despite reporting moderate pain on 7/19/25, 7/20/25, 7/21/25, 7/22/25, 7/23/25, and 7/24/25. This failure resulted in over-medication and inadequate pain management practices of Resident 79 which had the potential to result in adverse consequences and complications which could lead to serious medical condition. 2. Licensed Nurses did not follow physician ordered acetaminophen medication when Resident 12 was administered acetaminophen for complaints of pain, the acetaminophen was ordered for temperatures above 101 degrees Fahrenheit. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three residents (Resident 1) had a non-slip mat on her wheelchair as a care plan intervention to reduce the risk of a fall. This failure had the potential for Resident 1 to have an increased risk of falls, potentially leading to injury including bone fracture, pain, and loss of function.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to provide one of one resident (Resident (R)118) reviewed for hospital transfers out of a total sample of 33 residents a written transfer notice when R118 was transferred to the hospital. This failure placed all residents and their representatives at risk of having incomplete information, misunderstand the reason of transfer/discharge, and the discharge appeal process.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to provide one of one residents (Resident (R) 118) reviewed for hospital transfers out of a total sample of 33 residents a written bed hold when R118 was transferred to the hospital. This failure This failure placed all residents of the facility at risk for the resident and/or responsible parties to not have the information needed to safeguard their return to the facility.

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to ensure a Registered Nurse (RN) was on duty eight consecutive hours in a 24 hour period, seven days a week. This placed all residents of the facility at risk for unmet clinical needs either directly by the lack of RN coverage or indirectly by the Licensed Practical Nurses (LPNs) or the Certified Nurse Aides (CNAs) for whom the RN was responsible for overseeing resident care.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents received adequate supervision and assistance based on the admission/fall risk assessment and care plan to prevent falls for one of four sampled residents (Resident 97) when Resident 97 with known history of falls, assessed as high risk for falls on 6/27/19 and required supervision while ambulating, was ambulating in his room unsupervised, fell and sustained injuries to his head and shoulder. This failure resulted in Resident 97's fall on 6/28/19, a head injury, a fracture (broken bone) of the left clavicle (collarbone), pain and suffering as a result of the injuries.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were treated with respect and dignity for meals served in the East Wing dining room for 7 of 16 sampled residents (Resident's 17, 31, 46, 53, 65, 99 and 108) when: 1. Certified Nursing Assistant (CNA) 4 stopped assisting Resident 17 and Resident 53 during lunch and Resident 17 and Resident 53 were kept waiting to be fed while CNA 4 assisted other residents (Residents 5 and 63) on different occasions. 2. CNA 5 stopped assisting Resident 65 and Resident 108 during lunch and Resident 65 and Resident 108 were kept waiting to be fed while CNA 5 assisted other residents (Residents 46 and 63) on different occasions. 3. Resident 31's, Resident 86's, Resident 53's and Resident 66's right to be served meals in an area designated for dining was not done. Instead the meals were served in the hallway by CNA 6. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents right to privacy during care for two of two sampled residents (Resident 23 and 89) when Licensed Vocational Nurses (LVN 3 and LVN 4) provided care to Resident 23 and 89 without closing privacy curtains during medication administration observation. This deficient practice resulted in Resident 23's and 89's right to privacy during the delivery of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS- assessment of healthcare and functional needs) assessment accurately reflected the resident's status for three of three sampled residents (Resident 2, Resident 15, and Resident 61) when: 1. Rejection of care was incorrectly coded in Section E (behavior) in four of five of Resident 2's MDS assessments. 2. Pressure ulcer was incorrectly coded in Section M (skin condition) of Resident 15's annual assessment. 3. Pain was incorrectly coded in Section J (health condition) of Resident 61's 5-day assessment. These failures resulted in an inaccurate assessments of Resident 2, 15 and 61's MDS assessment, resulted in care plans for refusal of weights to not be addressed and updated in IDT meetings for Resident 2, and had the potential to result in Resident 15 and 61's care needs going unmet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services in accordance with professional standards of quality for three of five sampled residents (Residents 23, 47, and 89) when: 1. Licensed Vocational Nurse (LVN) 3 and LVN 4 signed the medication administration record (MAR) prior to the administration of medications to Resident 23, 47, and 89. These failures had the potential to place Resident 23, 47, and 89 at risk for medication errors. 2. LVN 3 did not follow the directions of use for Resident 23's medication order for stool softener. This failure had the potential to place Resident 23 at risk for developing bowel complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient staffing to provide care and services to ensure residents received the needed care to attain and maintain their highest practicable physical, mental and psychosocial well-being for the eight of 16 sampled residents (Resident's 17, 31, 46, 53, 65, 86, 99, and 108) when three Certified Nursing Assistants (CNA) were unable to provide residents with full attention, continuous and uninterrupted feeding assistance during meal service. These failures had the potential to result in Resident's 17, 31, 46, 53, 65, 86, 99, and 108 not meeting their daily nutritional needs and could lead to unplanned weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of four medication carts were locked and medications were securely stored when: 1. Licensed Vocational Nurse (LVN) 3 left the medication cart unlocked and unattended. 2. LVN 11 left the medication unlocked and left Resident 91's medications on top of the medication cart, unattended and accessible to residents, staff and visitors passing by in the East Wing hallway. These failures placed residents at risk of actual or potential for harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 13 of 13 sampled residents (Resident 29, 33, 37, 43, 47, 63, 66, 69, 71, 89, 94, 112, and 118) received the menu as planned during a dining observation when: 1. One of one Dietary Aides (DA 1) did not adjust the pureed recipe menu for pasta to account for the number of servings she was pureeing (a paste or thick liquid suspension usually made from cooked food ground finely). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety in the kitchen when: 1. One dented can of puree pumpkin was stored with the undented canned food and was available for use in residents food. 2. One can of tomato base bullion with an expiration date of 2/20/19 (five months prior) was stored on a kitchen shelf and available for use in residents food. 3. Six open bags of bread were stored in the kitchen and available for use in residents food were not labeled with opened dates. 4. One unlabeled and undated, plastic container of a white powdered substance (food and liquid thickener) was stored in the kitchen and available for use in residents' pureed food. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records on each resident that are complete, accurately documented and readily accessible for two of six sampled residents (Resident 61 and Resident 83) when a copy of Physician Orders for Life-Sustaining Treatment (POLST) form (a legal document that specifies the type of care a resident's treatment and services would like in an emergency life threatening medical situation) was not readily available as part of Resident 61 and Resident 83's current medical records. This failure had the potential risk for Resident 61 and Resident 83's decisions regarding their healthcare and treatment options not being honored.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an infection prevention and control program when: 1. Five Certified Nursing assistant (CNA's 4, 5, 6, 10, and 11) and one Licensed Vocational Nurse (LVN) 6 did not perform hand hygiene before, between and after physical contact with 11 of 22 sampled residents (Resident 5, 17, 31, 46, 53, 63, 65, 72, 86, 99, and 108) during lunch meal service in the dining room. 2. License Vocational nurse (LVN) 4 did not disinfect her stethoscope (medical instrument for listening to heart or breathing sounds) after each resident use. These deficient practices had the potential to result in cross contamination and placed residents at risk for infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient space in the East Wing dining room (the smaller of two facility dining rooms) to safely and comfortably accommodate 16 of 16 (Residents 5, 17, 26, 30, 31, 46, 53, 63, 65, 66, 72, 78, 81, 86, 99, and 108) sampled residents who ambulate (walk), use walkers and wheelchairs (mobility devices). During meal times (breakfast, lunch and dinner); tables, chairs and mobility devices blocked the entrances and exits of the dining room and did not provide comfortable spacing between residents. Facility staff did not develop and implement a plan to maintain safe passage in and out of the dining room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to use the least restrictive alternative for the least amount of time and to assess and document ongoing re-evaluation of the need for restraints in accordance with the facility's policy and procedure for one of three sampled residents when Resident 520 was prescribed a tab alarm on admission without using a less restrictive alternative and was not assessed or re-evaluated for 14 days. This deficient practice unnecessarily restrained Resident 520 and kept her from freely moving and reaching for items for fear of setting off the alarm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a baseline resident centered care plans (a plan that provides direction for individualized care of the resident) were developed and implemented to meet the identified needs of two of four sampled residents (Resident 60 and 520) when: 1. Resident 60 did not have a fall risk care plan with interventions to address Resident 60's safety risks to prevent fall. 2. Resident 520's tab alarm care plan did not include interventions and goals. 2b. Resident 520 did not have a tab alarm restraint care plan. These failures affected Resident 60 and 520's quality of care and needs not being addressed and resulted in Resident 60's fall and contributed to Resident 520's unnecessary restraints.

Inspectors wroteBased on interview and record review, the facility failed to timely revise and implement a person-centered comprehensive care plans for one of three sampled residents (Resident 2) when Resident 2's refusals of physician ordered weights was not reviewed and revised by the interdisciplinary team (IDT - A coordinated group of experts from several different healthcare fields who work together toward an identified resident goal). These failures directly contributed to a severe weight gain of 92 pounds within 11 months and placed Resident 2 at an increased risk for health related complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure activities of daily living (ADL) were provided to maintain good grooming for one of 57 sampled residents (Resident 42) when Resident 42's finger nails were long and contained a black substance under the nail beds. This failure resulted in Resident 42's nails not being well groomed and the potential for harboring microorganisms (bacteria, virus, or fungus) or infection.