Community Care on Palm

In the surveyor’s words

From the most serious findings on record at Community Care on Palm, in the surveyor’s own words.

• Immediate jeopardy, patternF727Jul 13, 2021

  Based on observation, interview, and record review, noncompliance by the facility to provide for leadership, oversight, resource, and support for 48 residents were identified when: Forty-eight residents were left without a Director of Nursing (DON) to assume ultimate responsibility to coordinate plans for the total care of each residents on May 12-31, 2021, June 1-6, 2021, and June 12-15, 2021. The facility's failure to ensure adequate 24- hour nursing coverage had the potential to result in over-all unsafe living conditions for the48 residents. Furthermore, forty-eight residents were left without a Registered Nurse (RN) on numerous occasions. […]

• Immediate jeopardy, isolatedF689Dec 20, 2021

  Based on observation, interview, and record review, the facility failed to monitor, to supervise and to manage, one of five residents (Resident 1) with wandering behavior. Resident 1 was assessed as high risk of wandering. In addition, the facility failed to implement interventions for Resident 1's wandering behavior. These failures resulted in a resident-to-resident altercations, and an incident of fall. Resident 1's wandering episode in another resident's room on October 14, 2021, resulted in the resident (Resident 1) being accidentally hit by a door causing an incident of fall. […]

• Actual harm, isolatedF600Jun 27, 2024

  Based on observation, interview, and record review, the facility failed to protect the resident ' s right to be free from physical abuse for one out of six residents reviewed (Resident 2), when another resident (Resident 1) hit Resident 2 on the head with a cane. This failure resulted in Resident 2 sustaining four lacerations (deep cut/tear in skin) on his head and bruising to his hands and shoulder. Resident 2 was transferred to the acute hospital, where he received 18 staples (surgical staples - used to close large wounds or deep cuts) to treat his head wounds. Findings: On June 4, 2024, at 9:10 a.m., an unannounced visit was made to the facility to investigate a facility-reported resident-to-resident altercation between Resident 1 and Resident 2 on June 1, 2024. […]

• Actual harm, isolatedF689Jun 27, 2024

  Based on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards for one out of six residents reviewed for accidents, when Resident 1 had access to a cane which he used to hit Resident 2. This failure resulted in Resident 2 sustaining four lacerations (deep cut/tear in skin) on his head and bruising to his hands and shoulder. Resident 2 was transferred to the acute hospital, where he received 18 staples (surgical staples - used to close large wounds or deep cuts) to treat his head wounds. Findings: On June 4, 2024, at 9:10 a.m., an unannounced visit was made to the facility to investigate a facility-reported resident-to-resident altercation. On June 4, 2024, at 9:10 a.m., the Director of Nursing (DON) was interviewed. […]

• Actual harm, isolatedF689Jan 4, 2024

  Based on observation, interview, and record review, the facility failed to ensure the safety for one of five residents reviewed for falls (Resident 1), when the fall risk care plan was not evaluated for effectiveness and updated to reflect new interventions to prevent further falls, and the fall risk assessments did not accurately reflect Resident 1's fall risk. This facility failure resulted in Resident 1 having repeated falls on November 16, 2023, November 22, 2023, and December 4, 2023. […]