Palm Valley Post Acute

In the surveyor’s words

From the most serious findings on record at Palm Valley Post Acute, in the surveyor’s own words.

• Immediate jeopardy, patternF609Nov 22, 2023

  Based on observations, clinical record reviews, resident and staff interviews, and facility documentation, policy and procedures, the facility failed to ensure that allegations of sexual abuse for one resident (#38) were reported immediately to the State Agency (SA) as required. The deficient practice resulted in resident subjected to further sexual abuse and could result in protection of other residents being compromised and increased risks for serious injury and harm. As a result, the Condition of Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified. Findings include: On November 17, 2023 at 6:53 p.m., the condition of IJ was identified. […]

• Immediate jeopardy, patternF610Nov 22, 2023

  Based on observations, clinical record reviews, resident and staff interviews, and facility documentation, policy and procedures, the facility failed to ensure that allegations of sexual abuse for one resident (#38) was thoroughly investigated. The deficient practice could result in protection of residents being compromised, residents are placed at increased risks for serious injury/harm and further abuse and appropriate corrective action not taken. As a result, the Condition of Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified. Findings include: On November 17, 2023 at 6:53 p.m., the condition of IJ was identified. […]

• Immediate jeopardy, isolatedF600Nov 22, 2023

  Based on observations, clinical record review, resident and staff interviews, review of facility documentation, policy and procedures the facility failed to ensure one resident (#38) was free from sexual abuse from staff. The deficient practice resulted in psychosocial harm to resident #38 and had placed residents at increased risk for further abuse, serious injury, harm and psychosocial harm. As a result, the condition of Immediate Jeopardy (IJ) and Substandard Quality of Care (SOC) were identified. The census was 164. Findings include: On November 17, 2023 at 6:53 p.m., the condition of IJ was identified. […]

• Actual harm, isolatedF684Feb 6, 2025

  Based on clinical record review, resident and staff interviews, facility documentation and policy review, the facility failed to ensure the necessary treatment and services were provided for 3 of 32 sampled residents according to professional standards regarding following physician orders for two residents (#95 and #77) and behavior monitoring for one resident (#108). The deficient practice resulted in resident hospitalization and could result in residents not receiving the necessary treatment, services and monitoring they need. […]

• Actual harm, isolatedF686Feb 6, 2025

  Based on observations, interviews, clinical record review, and review of facility policy, the facility failed to ensure pressure ulcer was assessed, monitored and treatment was provided for one sampled resident (#95). The deficient practice could result in development and/or worsening pressure ulcers. Findings include: Resident #95 was admitted on [DATE], with diagnoses of chronic respiratory failure, quadriplegia, tracheostomy status, dependence on respirator (ventilator) status, cerebellar stroke syndrome, history of sudden cardiac arrest, and chronic pain. The care plan dated November 29, 2023 revealed the resident was at risk for skin breakdown related to quadriplegia and hypoxia. […]