Palm Terrace Healthcare & Rehabilitation Center

In the surveyor’s words

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

• Actual harm, isolatedF684Feb 9, 2026

  Based on observation, interview, medical record review, facility document review, facility P&P review, and hospital Encounter Summary review, the facility failed to provide the necessary services and interventions to maintain the highest practicable well-being for one of three sampled residents (Resident 103) reviewed for closed record; and for one of 22 final sampled residents (Resident 10) reviewed for meal observation. * Resident 103 was in his room when LVN (Licensed Vocational Nurse) 8 noted the resident with oral secretions. LVN 8 performed oral suction and then obtained Resident 103's vital signs which included the blood pressure, heart rate, respiratory rate, oxygen saturation (measures the percentage of oxygen-carrying hemoglobin in the blood), and temperature. […]

• Actual harm, isolatedF726Feb 9, 2026

  Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure five out of five licensed nurses reviewed for competency had specific competencies and standard of practice skill sets needed to provide safe and efficient nursing care. * The facility failed to ensure LVN 8 had the appropriate competency and skill set to assess and provide interventions when Resident 103 was in critical condition experiencing desaturation (a drop in oxygen levels in the blood), hypothermia (a dangerous, potentially fatal medical emergency where the body loses heat faster than it produces it, causing the core temperature to drop below 95 degrees Fahrenheit), and hypertension (high blood pressure). […]

• No harm, potential for more than minimal, widespreadF812May 24, 2022

  Based on observation, interviews, facility P&P review, and facility document review, the facility failed to ensure the safe and sanitary food preparation and storage practices in the kitchen as evidenced by: * Fruit flies were observed in the kitchen . * Multiple areas in the kitchen, kitchen equipment, and food storage areas were not cleaned. * The sanitizer red bucket was stored above the clean sheet pans. * Three opened food items (corn kernel, diced carrot, and hot dog) were found in the reach-in freezer. * The dietary staff stored the personal items (drinks) in the kitchen. * Several resident beverages brought in by families were not labeled. […]

• No harm, potential for more than minimal, widespreadF925May 24, 2022

  Based on observation, interview, and facility P&P review, the facility failed to maintain an environment free of pests. * Fruit flies were observed on multiple days in the food storage and food production areas. This failure had the potential to cause cross contamination of food and food production surfaces as well as the spread of infections in the facility. Findings: Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility dated 5/17/22, showed 90 of 91 residents in the facility received food prepared in the kitchen. Review of the Food and Drug Administration Federal Food Code 2017 showed Insects and other pests are capable of transmitting disease to humans by contaminating food and food-contact surfaces. […]

• No harm, potential for more than minimal, patternF605Feb 9, 2026

  Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure six of 22 final sampled residents (Residents 2, 3, 5, 14, 27, and 106) were free from the unnecessary psychotropic medications. * The facility failed to ensure the alprazolam (antianxiety medication) was administered to Resident 2 as per the physician's order. The facility failed to ensure the behavior manifestation was monitored and documented, and the non-pharmacological interventions were provided prior to the administration of the alprazolam medication. * The facility failed to ensure the monitoring of Resident 3's meal intake was accurate to identify when the resident had a meal intake of less than 50% related to the use of mirtazapine (antidepressant medication). […]