Palms Care Center

Inspectors wroteBased on interview and record review, the facility failed to accurately and appropriately act on a significant change of condition on 7/7/26 for one of five residents (Resident 1) in accordance with professional standards of practice and facility's policy and procedure when Resident 1 was admitted to the facility on [DATE] for rehabilitation and on 7/6/26 Resident 1 was alert, cooperative, progressing with care goals, and was able to ambulate 25 feet. Resident 1 experienced an acute clinical decline the morning of 7/7/26 when staff noted Resident 1 was difficult to arouse from sleep, refused to get up and not able to ambulate, refused meals, and was found to have a high blood sugar. Nursing did not accurately provide the clinical decline assessment to the physician. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure daily nurse staffing information contained all required information when the total number of hours and actual hours worked by Registered Nurse (RN)s, Licensed Vocational Nurse (LVN) s, Licensed Practical Nurse (LPN)s, and Certified Nursing Assistant (CNA)s were not separated, and was not posted in a prominent readily accessible location to 60 out of 60 residents and visitors. This failure resulted in restricted public access to posted nurse staffing information for 60 out of 60 residents admitted within the facility which had the potential to result in residents not knowing how many direct care hours were provided daily.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (CP - a detailed approach to care customized to an individual resident's needs) for three of 14 sampled residents (Resident 28, 37, 41) when: 1. Resident 37's CP did not address Resident 37's preference to maintain an ileostomy (is a surgical procedure where the end of the small intestine (ileum is brought through an opening in the abdomen (stoma) to allow waste to exit the body through a bag instead of the anus) and to manage the associated risk. This failure placed Resident 37 at risk for stoma complications and not to honor residents' choice while ensuring proper care. 2. Resident 41's CP was not developed to address the ongoing medication refusal. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an infection prevention and control program was maintained for 7 of 14 sampled residents (Resident 4, 9, 10, 22, 48, 50, and 261), when: 1. Licensed Vocational Nurse (LVN) 1 and LVN 2 did not perform hand hygiene [cleaning hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based rub (ABHR)] between Resident 10, 22, 48, 50, and 261 during medication administration. This failure had increased risk of cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effects) and the spread of infection. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards of practice for two of 11 sampled residents (Resident 28 and Resident 57) when: 1. Resident 28 sustained wounds due to continued itching and picking (pulling off dried skin and scabs) from her wounds on her right, left arms and right shoulder and Licensed Vocational Nurses (LVN)s did not notify the physician. This failure resulted in Resident 28 having open, bleeding and unhealing wounds which put Resident 28 at risk for infection and continued discomfort. 2. Resident 57's oxygen therapy (a colorless, odorless, tasteless gas essential to living organisms) was not administered per the physician order. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 261) was provided activities that met his preferences and interests to support mental and psychosocial well-being when Resident 261's developed activities did not match his interests or preference to write, draw or color. This failure had the potential for Resident 261 to result in isolation and decreased engagement in activities.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the Registered Dietitian (RD) offered adequate consultation to support food and nutrition services, residents' assessments and the development of individualized care plans for one of six sampled residents (Resident 39), when RD did not follow up with weight changes for Resident 39. This failure had the potential to cause reduced quality of life and risk of weight loss, dehydration and delayed wound healing.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate and complete medical records in accordance with professional standards of practices were maintained for one of seven sampled residents (Resident 28), when the Physician Orders for Life-Sustaining Treatment (POLST- a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) was not accurate and complete. This failure had the potential for Resident 28's decisions regarding treatment options and end of life wishes to not be honored.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure call lights were within reach for two of six sampled residents (Resident 4 and 9) when call lights were observed on the floor and tucked in bedside drawers out of resident reach. These failures had the potential for Resident 4 and 9 to have delayed medical attention, increased risk of falls, prolonged discomfort or pain, feelings of isolation and anxiety (feeling of worry or nervousness), and in severe cases, life-threatening situations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision and monitoring for one of six sampled residents (Resident 1) when Resident 1 had a history of aggressive behavior towards other residents and staff did not implement interventions to protect other residents. On 7/12/24 Resident 1 was left unattended in the dining room. Resident 1 hit Resident 2 with a closed fist to his left hand. Resident 1 had a care plan intervention for one on one (1:1-constant observation for safety of residents) supervision. This failure resulted in Resident 1 not being supervised in the dining room and striking Resident 2 on his left hand, causing injuries to Resident 2 ' s left hand that required treatment for a skin tear (a wound that is caused by direct contact between the skin and another object) and bleeding to his left hand.

Inspectors wroteBased on interview and record review the facility failed to hire a qualified Dietary Manager (DM) to carry out the functions of the food and nutrition services for 56 of 61 residents who receive food from the kitchen when the dietary supervisor did not meet the minimum qualifications for the role. This failure had the potential to affect the nutrition status and health of 56 of 61 residents who receive food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe preparation, distribution, and storage practices were followed in the kitchen for 56 of 61 residents in accordance with facility policy and procedure and the US Food Code when: 1. The top of the dish washer had crumbs, dust, and was covered in a white residue (material that gets leftover after not being cleaned for some time). 2. The cooking surface of three of seven pans was cracked and peeling. 3. The walk-in freezer had a large icicle (hanging piece of ice that grows as water drips). 4. Oven mitts were torn at the tip and the inside fabric was exposed. These failures had the potential to attract pests, contaminate residents' food, and cause foodborne illnesses to 56 of 61 sampled residents who receive food from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to meet professional standards of practice for three of eight sampled residents (Residents 8, 11 and 57) when: 1. Licensed Vocational Nurse (LVN) 2 failed to follow facility's procedure on Proper Inhalation Technique for Metered Dose Inhaler (MDI-small, hand-held device filled with medicine to treat breathing problem) when she administered MDI medication to Residents 11 and 8. This failure had the potential for Residents 8 and 11 to suffer from respiratory infection which could lead to serious health condition. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a physician Informed Consent (the process in which residents are given important information of the possible risk and benefits of psychoactive medications) for the use of psychotropic medication (medication capable of affecting mind, emotions, and behavior) was obtained for one of six sampled residents (Resident 26) when Resident 26 was administered quetiapine fumarate and risperidone (medications used to treat anxiety [intense excessive, and persistent worry and fear about everyday situations]) on 3/26/24 to 4/8/24 and informed consent was not obtained prior to medication administration. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor resident's rights for one of eight sampled residents (Resident 12), when Resident 12 was not informed or allowed to decline plan of care. Resident 12 was placed on a low air loss mattress (LAL-enhancing circulation and reducing prolonged pressure in one area) that was contraindicated for fitted sheets and resident's request for fitted sheets was not addressed. This failure resulted in Resident 12 feeling frustrated, ignored, disrespected and physically uncomfortable when she was not allowed to have fitted sheets on her mattress.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a clean and homelike environment for one of 18 sampled residents (Resident 45), when Resident 45's room had chipped, missing and peeling paint on the walls of the bathroom and mirror. This failure had the potential for Resident 45 to not have living space in a homelike environment and possibly feeling depressed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Minimum Data Set assessment ((MDS -assessment of physical and psychological functions and needs) accurately reflected resident's health and functional status for one of three sampled residents (Resident 57) when Resident 57's functional limitation in range of motion was inaccurately coded on the MDS assessment. This failure had the potential to result in Resident 57's care needs not being met.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive care plan for one of six sampled residents (Resident 57) when Resident 57 was administered apixaban (anticoagulant-blood thinner) medication for atrial fibrillation (an irregular, often rapid heart rate that commonly caused poor blood flow and blood clot formation) and the facility did not initiate a care plan for apixaban. This failure placed Resident 57 at a potential risk for use of anticoagulant needs not met.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles when Licensed Vocational Nurse (LVN) 6 did not lock her medication cart and went inside a resident room to administer medication. This failure had the potential for residents, staff, and visitors to have access to the unlocked medication cart.

Inspectors wroteBased on observation and interview, the facility failed to establish and maintain an infection control program to provide a safe, sanitary, and comfortable environment to help prevent infection for one of three sampled residents (Resident 40) when Licensed Vocational Nurse (LVN) 7 failed to sanitize (disinfect) the blood pressure cuff (device used to measure the pressure of blood in the circulatory system), stethoscope (device used to listen to internal sounds of a human body or an animal) after use and did not wash her hands after checking the blood pressure of Resident 40. These failures 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.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an environment free from accident hazards for three of three sampled residents (Resident 1, Resident 3 and Resident 4) when Residents were not educated on oxygen safety precautions. This failure resulted in Resident 1 being burned from when her oxygen tubing caught fire and had potential for Resident 3 and 4 being burnt.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure five of five Residents (Residents 6, 8, 11, 16, and 55) were assessed for the risk of entrapment (resident caught, trapped, or entangled in the space in or about the bed and side rail) from bed (side) rails (adjustable metal or rigid plastic bars in various sizes that attach to the bed, and can be placed in a guard (raised) or lowered) prior to installation and had no consent (form signed by resident or family explaining the risks of side rail use), physician order, indication for use, and care plans prior to the use of side rails when: 1. Resident 6 had two bed rails raised up and had sustained an injury of unknown origin on 10/29/2021 prompting the facility to pad the bed rails. Prior to the use of the two bed rails, staff did not conduct an entrapment risk assessment; [...]

Inspectors wroteBased on 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 five of six sampled residents (Residents 3, 10, 18, 19 and 20) when residents' needs, preferences, and accommodations were communicated to staff, and staff did not respond in a timely manner. These failures resulted in Residents 3, 10, 18, 19 and 20's needs not being met.

Inspectors wrote3. During a concurrent observation and interview on 11/2/21 at 2:26 p.m., with Resident 32, in Resident 32's room, Resident 32 was laying in bed with the catheter bag touching the ground. Resident 32 stated, after lunch the Certified Nursing Assistant (CNA) emptied his catheter bag. During a concurrent observation and interview on 11/2/21, at 2:35 p.m., with CNA 6, in Resident 32's room, Resident 32's catheter bag was touching the ground. CNA 6 stated, the catheter bag should not be on the ground because there was a risk for infection and cross contamination. During a review of Resident 32's Care Plan, dated 11/2/21, the Care plan indicated, .Alteration in elimination of bowel and bladder .Keep drainage bag of catheter below the level of the bladder at all times and off floor . [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food safety when two spices were expired, one applesauce container was not labeled and did not contain the use by date (last date recommended for the use of a product while at peak quality). These food items were available in the kitchen for use to prepare food for 57 out of 57 residents. This failure placed 57 residents at risk for foodborne illnesses (illnesses caused by consuming contaminated food or drink) from consuming potentially contaminated food (unclean) and exposure to harmful pathogens (bacteria or viruses that can cause illness) and decrease palatability of the food.

Inspectors wroteBased on interview and record review, the facility failed to develop a policy and procedure allowing residents to have outside food brought in by the family and/or visitors ensuring sanitary and safe food storage for six of six sampled residents (18, 19, 35, and 51) when residents were informed, they were not allowed to store and/or reheat prepared food brought to them by family. This failure had the potential for unsafe and unsanitary food storage and handling brought from outside for later consumption and placed Residents 18, 19. 35 and 51at high risk for food borne illnesses.

Inspectors wroteBased on interview, and record review, the facility's Administrator (ADM) failed to ensure effective oversight and necessary resources to ensure resident care services were met to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident when the ADM did not provide oversight to the facility's day to day operations when: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective infection control program when: 1. One of three sampled residents (Resident 27's) gastrostomy tube (a tube inserted through the wall of the abdomen directly into the stomach. The tube allows patients to receive nutrition directly through stomach) gravity bag (gravity feeding is a way to deliver feeding formula through the feeding tube. With this feeding method, formula flows out of a bag and into the tube by gravity) lid was left open when the feeding formula was being administered. This failure had the potential to result in Cross contamination for Resident 27. 2. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure the designated Infection Preventionist (IP-professional who ensures healthcare workers and patients are doing all the things they should to prevent infections) completed the specialized training for IP certification program in accordance with the facility's policy and procedure and CMS (Centers for Medicare and Medicaid Services) guidelines. This failure resulted in the IP not meeting the qualifications that would ensure residents were provided with quality care to prevent or minimize the transmission or spread of COVID-19 (a contagious serious respiratory infection transmitted from person to person) and/or other infections to all residents and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure emergency exit routes must be clear and unblocked to allow quick and safe exit for facility residents, staff and visitors in case of an emergency when mechanical lifts, wheelchairs, shower beds where stored in front of the emergency exit doors in the hallway. This failure had the potential to create delay, panic, and confusion to residents, staff, and visitors in case of an emergency.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide services which meet professional standards of quality for three of 43 sampled residents (Resident 40, Resident 110, and Resident 56 .) when: 1. Resident 40 was administered oxygen without following physician's order. This failure resulted in Resident 40 to receive a high dose of oxygen and had the potential to experience oxygen toxicity (a lung damage that happens from breathing too much (supplemental) oxygen. It can cause coughing and trouble breathing. In severe cases it can even cause death.) Which can lead to difficulty in breathing and death. 2. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the facility medication error rate did not exceed five percent when the facility medication error rate was 16 percent when 25 opportunities of medication administration were observed and four of the 25 medications were not administered in accordance with physician's orders, resulting in a medication error rate of 12 percent. These failure placed Resident 110, and Resident 56 at risk for inaccurate insulin dosage and impaired insulin absorption (movement of a medication from the site of administration to bloodstream) and not getting the full therapeutic effects of all the administered medications.

Inspectors wroteBased on Observation, Interview, and Record Review the facility failed to ensure residents were free from significant medication error for two of six sampled residents (Resident 110, and Resident 56) when: 1. Licensed Vocational Nurse (LVN) 8 administered Amoxicillin-Pot Clavulanate (a medication use to treat infection) not following physician's order administration time, and administered insulin (medication used to treat high blood sugar) by way of an insulin pen (a device used to inject insulin) to Resident 110 without priming prime (a method to remove air bubbles from the needle to ensure it is working, and provides insulin full dose administration) the insulin pen and without allowing the pen needle to remain under the skin for 5 to 10 seconds. 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to protect the privacy of personal information for one of 43 sampled residents (Resident 110) when Licensed Vocational Nurse (LVN) 8 did not close Resident 110's Electronic Health Record (EHR- are electronic versions of the paper charts. An EHR includes resident's medical history, notes, and other information about health including symptoms, diagnoses, medications, lab results, vital signs, immunizations, and reports from diagnostic tests). The EHR were left open, unattended and exposed for public viewing. This failure had the potential for unauthorized access to resident's personal information and violated Resident 110's right to privacy and confidentiality.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and timely revise a person-centered comprehensive care plan for one of three sampled Residents (Resident 18) when: 1. Resident 18's care plan for use of indwelling urinary catheter (IUC-a catheter drains urine from your bladder into a bag outside the body) was not reviewed or revised by the Interdisciplinary Team (IDT-group composed of a physician, a nurse and appointed facility staff who meet and discuss the care of the residents). This failure had the potential for Resident 18's to develop urinary tract infections (UTI-infection of the urinary tract) and not following his specific care needs for the IUC.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure bowel and bladder training program was developed for one of three sampled residents (Resident 18) when Resident 18' s bowel and bladder (B&B) training program (a training program to overcome bladder problems) was not developed for the indwelling urinary catheter (IUC-a catheter drains urine from your bladder into a bag outside your body). This failure had the potential for Resident 18's to develop urinary tract infections (UTI-infection of the urinary tract) and loss of opportunity to regain bowel and bladder function.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide enteral G-tube (Gastrostomy tube that is placed directly into the stomach for administration of food, fluids, and medications) feeding per physician order, for one of three sampled residents (Resident 42) when; Resident 42 did not have training to self-administer enteral feeding and administered an incorrect formula by adding water to his enteral feeding. This failure resulted in Resident 42 receiving more water than prescribed and had the potential to cause adverse complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs were labeled in accordance with currently accepted professional standards of practice for one of 43 sampled residents (Resident 2) when Resident 2's artificial eye drops container was stored in the medication cart in the hallway without an open and used by date. These failures had the potential to result in the contamination, decreased efficacy of eye drops which placed Resident 2 at risk for decrease eye moisture and getting an eye infection.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure the food service staff had the appropriate competencies and skills sets to carry out the functions of the food service when one of seven dietary staff (Cook-CK 4) worked in the kitchen with an expired food handler card (FHC-proof of certification required of all food handlers in certain states within the United States. A food handler is defined as a person who works in a food facility and performs any duties that involve the preparation, storage or service of food in a facility). This failure had the potential to place residents at risk for unsafe food practices and handling which may lead to food borne illnesses (is any illness resulting from the spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food).

Inspectors wroteBased on interview and record review, the facility failed to maintain an effective abuse training program for one of three employees (Licensed Vocational Nurse (LVN) 6) when employee training was not tracked, and employee did not complete the mandatory training necessary to identify and report abuse to meet the needs of the residents. This failure placed residents at risk for abuse, neglect, and exploitation.