Palm Terrace Care Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812May 16, 2025

  Based on observation, interview, and record review, the facility failed to ensure food safety and sanitation practices were maintained in the kitchen according to standards of practice and facility policy, for 67 out 68 residents who eat food from the kitchen, when: 1. Four (4) large metal pans with food debris and dripping water on them were stored and stacked on top of each other on a bottom shelf; and 2. One 50-pound (lb- unit of measurement) bag of instant milk nonfat dry powder was found stored with an open tear in the bag, with food product seeping out and with clear tape covering it. These failures exposed residents' to contaminated food and unsanitary practices, which had the potential to place them at risk of developing a foodborne illness. Findings: 1. […]

• No harm, potential for more than minimal, widespreadF925May 16, 2025

  Based on observation, interview, and record review, the facility failed to ensure food safety and sanitation practices were maintained in the kitchen according to standards of practice and facility policy, for 67 out of 68 residents who consume food from the kitchen, when pests (a roach, a spider, and ants) were observed in the dry food storage pantry. In addition spiderwebs were also observed inside the kitchen. These failures had the potential to expose residents to contaminated food, that could result in food borne illnesses for all residents who consume food from the kitchen. Findings: On May 12, 2025, at 07:01 a.m., a concurrent observation and interview was conducted in the facility's kitchen dry food storage room with the Dietary Supervisor (DS). […]

• No harm, potential for more than minimal, widespreadF802May 10, 2024

  Based on observation, interview, and record review, the facility failed to ensure the dietary staff were able to carry out the functions of food and nutrition services safely and effectively when: 1. Food service workers did not follow the facility's cleaning procedure to clean food preparation surfaces and stationary equipment. (Cross referred F 812) This failure had the potential to cause foodborne illness for 64 of 64 sampled residents who received food from the kitchen. 2. [NAME] (CK) 1 served chunky pasta for 10 of 10 sampled residents who had a physician prescribed pureed diet (food that has been ground, pressed and/or strrained to a soft smooth consistency like pudding) during lunch on May 8, 2024. […]

• No harm, potential for more than minimal, patternF558May 16, 2025

  Based on observation, interview, and record review, the facility failed to ensure call lights were answered in a timely manner, for six out 68 residents (Residents 10, 27, 37, 55, 56 and 163). This failure had the potential for the residents' emotional, psycho-social, and optimal physical well-being to not be met. Findings: 1. On May 12, 2025, at 9:55 a.m., an interview was conducted with Resident 10 in her room. Resident 10 stated it would take time for the staff to answer her call light during the morning shift. Resident 10 stated she had waited an hour for someone to come during the night shift and it was frustrating. A review of Resident 10's medical record indicated she was admitted on [DATE], with diagnoses which included surgical aftercare following skin and tissue infection. […]

• No harm, potential for more than minimal, patternF725May 16, 2025

  Based on interview and record review, the facility failed to ensure sufficient staff were provided to meet the needs of the residents when the facility did not meet the required or minimum of Actual Total CNA Direct Care Service Hours for CNA DHPPD (DHPPD - measure the numbers of hours of direct care given to residents in skilled nursing facility) of 2.4 hours for March 1, 2025, of 31 days reviewed and April 5, 2025, of 30 days reviewed. The failure to maintain a the required minimum CNA DHPPD hours had the potential to increase the resident's risk of fall and to meet residents' requests for assistance with activities of daily living. […]