Palatka Center for Rehabilitation and Healing

In the surveyor’s words

From the most serious findings on record at Palatka Center for Rehabilitation and Healing, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF641Jul 16, 2026

  Based on observation, interview, and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were complete and accurate for 8 of 15 residents, Residents #2, #3, #8, #9, #112, #73, #139, and #153, reviewed Minimum Data Set assessments.Findings include: 1) Review of Resident #2's physician order dated 4/2/2026 read, Olanzapine Oral Tablet 5 MG [Milligram] (Olanzapine) give 1 tablet by mouth at bedtime for schizophrenia. Review of Resident #2 Medication Administration Record for the month of April 2026 documented the resident was administered Olanzapine for schizophrenia for the look back period of 4/2/2026 through 4/8/2026. Review of Resident #2's MDS titled Medicare 5 Day dated 4/8/2026, under Section I – Active Diagnoses, schizophrenia was not documented. […]

• No harm, potential for more than minimal, patternF684Jul 16, 2026

  Based on observation, interview and record review the facility failed to ensure wound care dressing changes were provided per physicians' orders for 4 of 7 residents, Resident #49, #58, #132, and #161 reviewed for skin conditions and failed to apply compression stockings per they physician order for 1 of 3 residents, Resident #150 reviewed for edema.Findings include: 1) During an observation on 7/13/2026 at 9:56 AM Resident #161 was lying in bed. There was a wound dressing on the resident's left ankle. The wound dressing was dated 7/11. [photographic evidence obtained] During an observation on 7/14/2026 at 9:00 AM Resident #161 was lying in bed. […]

• No harm, potential for more than minimal, patternF761Jul 16, 2026

  Based on observation, interview, and record review the facility failed to ensure medications were securely stored when unattended for 2 of 4 hallways.Findings include: 1) During an observation on 7/13/2026 at 9:31 AM Resident #53 was sitting in her room. On top of the resident's nightstand there was a medication cup with a white cream. During an interview on 7/13/2026 at 9:31 AM Resident #53 stated, The nurses give me that cream so I can apply it to my hands and feet it has lidocaine. I use it for my neuropathy pain. During an interview on 7/13/2026 at 1:23 PM Staff E, Licensed Practical Nurse (LPN) stated, [Resident #53's name] is not able to self-administer medication. […]

• No harm, potential for more than minimal, patternF842Jul 16, 2026

  Based on observation, interview, and record review the facility failed ensure residents' records were complete and accurate for 5 of 7 residents, Residents #49, #58, #132, #161, and #150, reviewed for documentation. Findings include: 1) During an observation on 7/13/2026 at 9:56 AM Resident #161 had a wound dressing on the resident's left ankle. The wound dressing was dated 7/11. [Photographic evidence obtained] During an observation on 7/14/2026 at 9:00 AM Resident #161 had a wound dressing on the resident's left ankle. […]

• No harm, potential for more than minimal, patternF756Feb 20, 2025

  Based on record review and interview the facility failed to provide a rationale when actions were not taken for pharmacy recommendations for 3 (Resident #7, #84, and #99) of 5 residents review for unnecessary medication. Findings include: 1)Review of Resident #7 Drug Regimen Review dated 7/10/2024 read, Consultant Pharmacist Recommendations. Currently receiving Oxybutynin (Ditropan) three times daily for urinary incontinence. Oxybutynin (Ditropan) can increase risk of dizziness and falls. Per clinical record, with recent falls. Periodic discontinuation recommended to determine current need and minimize resistance to the drug. Please evaluate, consider trail taper to two times daily with eventual discontinue, if appropriate . Physician Response: Disagree with no rationale included. […]