Palms Care Center

In the surveyor’s words

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

• Immediate jeopardy, patternF700Nov 10, 2021

  Based on observation, interview, and record review, the facility failed to ensure five of five Residents (Residents 6, 8, 11, 16, and 55) were assessed for the risk of entrapment (resident caught, trapped, or entangled in the space in or about the bed and side rail) from bed (side) rails (adjustable metal or rigid plastic bars in various sizes that attach to the bed, and can be placed in a guard (raised) or lowered) prior to installation and had no consent (form signed by resident or family explaining the risks of side rail use), physician order, indication for use, and care plans prior to the use of side rails when: 1. Resident 6 had two bed rails raised up and had sustained an injury of unknown origin on [DATE] prompting the facility to pad the bed rails. […]

• Actual harm, isolatedF684Jul 27, 2026

  Based on interview and record review, the facility failed to accurately and appropriately act on a significant change of condition on 7/7/26 for one of five residents (Resident 1) in accordance with professional standards of practice and facility's policy and procedure when Resident 1 was admitted to the facility on [DATE] for rehabilitation and on 7/6/26 Resident 1 was alert, cooperative, progressing with care goals, and was able to ambulate 25 feet. Resident 1 experienced an acute clinical decline the morning of 7/7/26 when staff noted Resident 1 was difficult to arouse from sleep, refused to get up and not able to ambulate, refused meals, and was found to have a high blood sugar. Nursing did not accurately provide the clinical decline assessment to the physician. […]

• Actual harm, isolatedF689Jul 30, 2024

  Based on observation, interview, and record review, the facility failed to ensure adequate supervision and monitoring for one of six sampled residents (Resident 1) when Resident 1 had a history of aggressive behavior towards other residents and staff did not implement interventions to protect other residents. On 7/12/24 Resident 1 was left unattended in the dining room. Resident 1 hit Resident 2 with a closed fist to his left hand. Resident 1 had a care plan intervention for one on one (1:1-constant observation for safety of residents) supervision. […]

• No harm, potential for more than minimal, widespreadF732Apr 4, 2025

  Based on observation, interview and record review, the facility failed to ensure daily nurse staffing information contained all required information when the total number of hours and actual hours worked by Registered Nurse (RN)s, Licensed Vocational Nurse (LVN) s, Licensed Practical Nurse (LPN)s, and Certified Nursing Assistant (CNA)s were not separated, and was not posted in a prominent readily accessible location to 60 out of 60 residents and visitors. This failure resulted in restricted public access to posted nurse staffing information for 60 out of 60 residents admitted within the facility which had the potential to result in residents not knowing how many direct care hours were provided daily. Findings: During a concurrent interview and record review on 4/3/25 at 1:54 p.m. […]

• No harm, potential for more than minimal, widespreadF801Apr 19, 2024

  Based on interview and record review the facility failed to hire a qualified Dietary Manager (DM) to carry out the functions of the food and nutrition services for 56 of 61 residents who receive food from the kitchen when the dietary supervisor did not meet the minimum qualifications for the role. This failure had the potential to affect the nutrition status and health of 56 of 61 residents who receive food from the kitchen. Findings: During an interview on 4/16/24 at 10:58 a.m., with the DM, the DM stated she was still in school to become a certified dietary manager. The DM stated she had not yet fully completed her schooling and training. The DM stated she was not certified as of 4/16/24. […]