Palms Care Center and Rehab

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Mar 19, 2021

  Based upon interview, observation and record review, the facility failed to appropriately assess a resident as an elopement risk and failed to provide supervision to prevent 1 of 3 sampled residents, assessed for elopement risk, from eloping, Resident #1. The deficient practice allowed Resident #1 to exit the facility undetected on [DATE] between 1:30 AM and 3:20 AM. The facility's system failure, lack of adequate supervision, an inaccurate risk of elopement assessment and an exit door not secured and without an alarm, allowed the resident to elope. The family provided directions to his previous residence and Resident #1 was found at approximately 4:30 AM. […]

• Immediate jeopardy, isolatedF689Mar 19, 2021

  Based upon interview, observation and record review, the facility failed to provide supervision and a safe environment to prevent 1 of 3 sampled residents assessed for elopement risk, Resident #1, from eloping. The deficient practice allowed Resident #1 to exit the facility undetected on [DATE] between 1:30 AM and 3:20 AM. The facility's system failure, lack of adequate supervision and an exit door not secured and without an alarm, allowed the resident to elope. The family provided directions to his previous residence and Resident #1 was found at approximately 4:30 AM. The Director of Nursing (DON) from the facility determined that the resident would be safest if he went to the hospital for evaluation, to which Resident #1 agreed. […]

• No harm, potential for more than minimal, widespreadF812Mar 4, 2021

  Based on observations and interviews, the facility failed to maintain food safety requirements with storage, preparation, and distribution in accordance with professional standards for food service safety which included failure to maintain sanitary conditions in the kitchen, failure to maintain adequate holding temperatures, and failure to transport meal trays under sanitary conditions. The findings included: 1. During the initial tour of the kitchen/foodservice department on [DATE] at 8:50 AM, accompanied by the Food Service Director (FSD), the following were noted: a) The Frigidaire reach-in freezer was observed with a 4 inch tear in the gasket on the door. The surveyor discussed that failure to have a proper gasket could result in improper food temperatures. […]

• No harm, potential for more than minimal, patternF584Oct 24, 2024

  Based on observation, interview, and record review, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable homelike interior for 3 of 3 residential units (200, 300, and 400), the Skilled Therapy Department, the Main Dining Room, the Activity Room, and the Main Lobby. The findings included: During the tour conducted on 10/21-22/24, resident meal observations conducted on 10/21-23/24, routine resident observations conducted on 10/21-23/24, and the environment tours conducted on 10/23-24/24 accompanied with the Corporate Maintenance Director, the Maintenance Director, and the Director of Housekeeping, the following were noted: 200 Resident Unit: room [ROOM NUMBER]: Room windows soiled, and window screens torn and in… […]

• No harm, potential for more than minimal, patternF803Oct 24, 2024

  Based on observation, interview, and record review, the facility failed to ensure that its Cycle menus (#1, #2, #3, and #4) met the nutritional requirements for daily milk / dairy servings and that the approved menu was being followed for potentially 105 of 113 facility's residents. The findings included: 1. During the review of the current Cycle menu in use (Cycle #3) on 10/21/24, it was noted that only 8-ounces on milk / dairy was being served to residents on a daily basis. An interview conducted with the Corporate Dietary Manager (CDM) at the time of the review to review documentation of why the facility menus did not include the required 16-ounces of milk per day to the residents ([AGE] years or older). […]