Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Palm Terrace Care Center during CMS and state inspections, most recent first.
A resident who had recently returned from the hospital and was combative during care allegedly experienced rough handling and yelling by a CNA during dressing, as witnessed by a therapy student (TS). The resident reportedly stated that a "mean lady" hit him. The TS reported his concerns to the PT lead and his clinical supervisor and later to APS, but did not immediately follow the facility’s internal chain of command. The PT lead did not fully explore the TS’s concern before passing it to the DOR, and the Administrator was not informed until the following morning. As a result, the allegation was not reported immediately to the Administrator/abuse coordinator as required by facility policy, delaying initiation of the abuse investigation and protective measures.
Surveyors observed that kitchen staff stored wet, dirty pans stacked together and failed to properly store a torn bag of powdered milk, which was only covered with tape and leaking product. The Dietary Supervisor and Registered Dietitian confirmed these practices did not meet facility policy or food safety standards, exposing residents to potential food contamination.
A deficiency was identified when pests, including a roach, spiders, and ants, were observed in the kitchen's dry food storage area, along with spiderwebs on metal carts. The Dietary Supervisor and Registered Dietician confirmed that pests should not be present and that their presence could contaminate food. Facility policies require food storage and service areas to be kept clean and free from pests.
Multiple residents reported experiencing long waits, sometimes up to an hour, for staff to respond to call lights, particularly during the night shift. Staff interviews confirmed that complaints about delayed responses were received, and the DON acknowledged that the facility's policy required call lights to be answered within five minutes. Despite these expectations, residents' needs for assistance with daily activities were not consistently met in a timely manner, leading to frustration and dissatisfaction.
On two reviewed days, the facility did not meet the required minimum CNA direct care service hours per patient day, as confirmed by record review and staff interviews. The shortfall was attributed to CNA turnover, and the facility's policy mandates sufficient staffing to meet resident care needs.
The facility failed to follow infection control protocols in three cases: a resident's annual TB test was not properly completed and documented; another resident's incentive spirometer was not stored in a labeled plastic bag as required; and a physical therapist did not wear PPE while providing care to a resident on Enhanced Barrier Precautions. These lapses were confirmed by facility staff and were not in accordance with established policies.
A resident with depression and diabetes was not served lunch at the same time as others at her table, resulting in a 30-minute delay while she waited and observed others eating. Staff interviews confirmed the meal was mistakenly placed on a different cart, and both the AD and LVN acknowledged this was a dignity issue. The DON stated that meals should be served simultaneously to all residents at a table, in accordance with facility policy on dignity and respect.
Surveyors found that two residents' rooms and a bathroom had areas of peeled paint on the walls and door frame, which was confirmed by both the Maintenance Supervisor and Administrator as not meeting the facility's standards for a homelike environment.
A resident with documented hearing loss and use of a left hearing aid was inaccurately assessed in the MDS, which stated the resident had adequate hearing and did not use a hearing aid. Both the MDS Nurse and DON confirmed the assessment did not reflect the resident's true status, contrary to facility policy and RAI manual guidance.
A resident with documented hearing loss and a non-functioning hearing aid did not receive a required audiology consultation, despite multiple staff recognizing the need and facility policy mandating such referrals. The resident's records consistently indicated hearing impairment and the need for evaluation, but no audiology services were provided.
A resident with missing teeth and difficulty chewing was not provided a timely dental consultation or referral for dentures, despite a physician's order and documented need. Staff interviews confirmed the expectation for referral, and facility policy requires coordination of dental evaluations, but this was not carried out.
A resident with Parkinson's disease who was on a mechanical soft, no added salt diet was not provided with necessary adaptive eating equipment, such as a plate divider, during mealtime. The resident was observed having difficulty keeping food on the plate, resulting in food spilling onto the floor. Staff interviews confirmed that the resident should have been evaluated and provided with appropriate assistive devices, in accordance with facility policy.
The facility failed to ensure proper cleaning procedures for food preparation surfaces and equipment, potentially risking foodborne illness for residents. Additionally, dietary staff did not adhere to prescribed pureed diets, serving chunky pasta to residents requiring smooth consistency, posing risks of aspiration and choking.
The facility failed to properly store medications in emergency medication supply containers (EKITs), leading to potential medication errors. Two EKITs were found with multiple different unit-dose medications mixed together in each compartment, including medications with similar-sounding names. The Consultant Pharmacist confirmed that medications should be stored separately to ensure safety and accuracy, aligning with facility policy and ISMP guidelines.
The facility failed to provide the correct food texture for residents on a pureed diet, serving chunky noodles instead of a smooth consistency. This was confirmed by a test tray and interviews with dietary staff, highlighting the risk of choking and aspiration for residents with difficulty swallowing.
The facility failed to maintain sanitary food preparation and storage practices, with staff not following proper cleaning procedures and a cook not covering his mustache. The kitchen had cracked tiles, missing grout, peeling paint, rusted shelves, and buildup on equipment, increasing the risk of contamination.
A facility failed to ensure a resident's Advance Directive (AD) was included in their medical record, despite the resident's acknowledgment of having one. The Social Service Director confirmed the AD should have been obtained and accessible, as per facility policy, but it was not available.
A resident did not receive milk and pureed soup as per their dietary preferences during a lunch meal. The Dietary Supervisor confirmed the omission and noted no alternative was offered. Facility policies require adherence to food preferences and checking meal trays for completeness, which was not followed in this instance.
A resident on a pureed diet was served a regular texture salad, contrary to physician orders, posing a risk of aspiration and choking. Additionally, the resident received a lower-calorie supplement than prescribed, potentially affecting weight gain. These discrepancies were confirmed by facility staff and highlighted a failure to adhere to dietary orders.
A Treatment Nurse in an LTC facility failed to change gloves and perform hand hygiene during wound care for a resident with a Stage 4 pressure ulcer, leading to a breach in infection control protocols. The resident had a local skin infection, and the facility's policy required specific steps for wound care, which were not followed.
Delayed Internal Reporting of Alleged Abuse by CNA
Penalty
Summary
The facility failed to ensure an allegation of abuse involving a certified nursing assistant (CNA) and one resident (Resident A) was reported immediately to the facility’s abuse coordinator/Administrator as required by its policy on reporting alleged violations of abuse, neglect, exploitation, or mistreatment. A therapy student (TS) observed an interaction in which the CNA, while providing care to Resident A, allegedly pulled the resident’s sheet, causing the resident to hit the bed railing, and yelled at the resident while changing the resident’s socks and shirt. Resident A, who had recently returned from the hospital and was described as combative during care, reportedly told the TS that a “mean lady” hit him. The CNA stated that Resident A had been combative and that the resident’s mouth bled when the resident rubbed it hard with a washcloth, and that she reported the bleeding to a licensed nurse. The TS reported his concerns to the Physical Therapy Lead (PTL) and his clinical supervisor on the day following the incident and then reported the allegation to Adult Protective Services (APS) that night, but he did not immediately report the allegation through the facility’s internal chain of command. The PTL acknowledged that when the TS came to him upset about a concern regarding the CNA, he did not ask for further details and only relayed the concern to the Director of Rehabilitation (DOR). The DOR stated he learned from the TS on the morning of February 18 that the TS had already reported the allegation to APS and then informed the Administrator at that time. The Administrator and DOR both stated that rehab students were instructed to report abuse allegations to their clinical instructor or to the DOR so the Administrator could be notified and the abuse protocol initiated immediately, but this did not occur, resulting in a delay in reporting the allegation internally and in implementing protective steps for the resident as required by facility policy.
Improper Food Storage and Sanitation Practices in Kitchen
Penalty
Summary
The facility failed to maintain proper food safety and sanitation practices in the kitchen, as observed by surveyors. Four large metal pans, including a perforated pan, were found stacked on a bottom shelf while still wet and with visible food debris and dripping water. The Dietary Supervisor confirmed that these pans were not clean and should not have been stored wet or with debris. The Registered Dietitian also stated that pans should be cleaned, dried, and stored properly to prevent cross-contamination. Additionally, a 50-pound bag of nonfat dry powdered milk was found in the facility's outside kitchen storage with an open tear, covered only by clear tape, and with food product seeping out. Both the Dietary Supervisor and Registered Dietitian confirmed that such damaged packaging should not be used, as it could allow pests to enter and contaminate the food. These findings were not in accordance with the facility's policies or the 2022 Federal Food Code, which require food-contact surfaces to be clean and food to be protected from contamination.
Pest Infestation Observed in Kitchen Food Storage Area
Penalty
Summary
The facility failed to maintain food safety and sanitation practices in the kitchen, as evidenced by the presence of pests in the dry food storage pantry. During an observation in the kitchen's dry food storage room, a roach, spiders, and ants were found on the floor, and spiderwebs were seen on metal carts. The Dietary Supervisor confirmed that pests should not be present in the dry food storage room and acknowledged that their presence could lead to contamination of food. Further interviews with the Dietary Supervisor and the Registered Dietician confirmed that the expectation was for the kitchen to be free of pests and that staff should report any pest sightings. Both staff members stated that pests could contaminate food, potentially making residents sick. Review of facility policies indicated that all food storage and service areas should be kept clean and free from insects, rodents, and other sources of contamination, in accordance with the 2022 Federal Food Code and facility procedures.
Failure to Answer Call Lights Promptly for Multiple Residents
Penalty
Summary
The facility failed to ensure that call lights were answered in a timely manner for six residents, as evidenced by multiple resident interviews, staff interviews, and record reviews. Several residents reported waiting extended periods, sometimes up to an hour, for staff to respond to their call lights, particularly during the night shift. Residents described feeling frustrated and anxious due to these delays, and some reported that their requests were simple, such as needing a blanket or water, but staff would sometimes acknowledge the call and not return. These concerns were communicated to staff and administration, but residents indicated that their complaints were not addressed. Medical records and assessments confirmed that the affected residents had varying degrees of physical and cognitive needs, with most being cognitively intact and requiring assistance with activities of daily living such as toileting, bathing, and mobility. Staff interviews corroborated the residents' accounts, with CNAs and an RN acknowledging that complaints about long call light wait times had been received, especially during the night and afternoon shifts. The DON confirmed that the facility's expectation was for call lights to be answered within five minutes and that all staff, including administration, were responsible for responding to call lights. The DON also acknowledged receiving complaints about long wait times and recognized the potential impact on residents' well-being. A review of facility policies and job descriptions indicated that staff were required to answer call lights promptly and provide routine checks to ensure residents' needs were met. Despite these policies, the documented experiences of the residents and staff interviews demonstrated that the facility did not consistently meet its own standards for timely response to call lights, resulting in unmet needs and resident dissatisfaction.
Failure to Meet Minimum CNA Staffing Requirements
Penalty
Summary
The facility failed to provide sufficient certified nursing assistant (CNA) staffing to meet the required minimum of 2.4 direct care service hours per patient day (DHPPD) on two specific days in March and April 2025. Record review and interviews with the Director of Staff Development (DSD) and Director of Nursing (DON) confirmed that on March 1 and April 5, the actual CNA direct care hours fell below the mandated threshold, with 2.36 and 2.32 hours respectively. The DON attributed the shortfall to turnover among nightshift CNAs and acknowledged that the facility's goal was to consistently meet staffing requirements. The facility's policy requires adequate staffing to provide care and services for all residents in accordance with the facility assessment.
Infection Control Deficiencies: TB Screening, Device Storage, and PPE Use
Penalty
Summary
The facility failed to implement proper infection prevention and control practices in three separate instances. For one resident, the Infection Preventionist (IP) did not ensure that the annual tuberculin skin test (TB test) was properly completed. The test was administered, but there was no documentation of the result being read after three days, as required by facility policy. Both the IP and the Director of Nursing (DON) confirmed that the test should have been repeated if the result was not read, in accordance with the facility's tuberculosis control plan. In another case, a resident's incentive spirometer was observed stored on top of a nightstand rather than in a labeled plastic bag as required by facility policy. The resident stated she did not have a plastic bag for storage, and the registered nurse (RN) confirmed that the device should have been kept in a plastic container. The IP and DON both acknowledged that improper storage of the spirometer could lead to respiratory infection, and the facility's policy specified that the device should be stored in a labeled plastic bag between uses. Additionally, a physical therapist (PT) was observed providing therapy to a resident on Enhanced Barrier Precautions (EBP) without wearing the required personal protective equipment (PPE). The resident had a PEG tube and was at risk for infection, with orders and care plans specifying the need for EBP and PPE during high-contact care activities. Both the IP and DON confirmed that the PT should have worn PPE in accordance with the facility's infection control policy.
Resident Not Served Meal with Peers, Dignity Compromised
Penalty
Summary
A deficiency occurred when a resident was not served lunch at the same time as other residents at her table. On the observed date, the resident, who was seated in a wheelchair with two other residents in the dining room, was not provided her meal while the others were served and began eating. The resident was seen waiting and inquired about her food, eventually receiving her meal approximately 30 minutes after the others. Staff interviews confirmed that the resident's meal tray had been mistakenly placed on a different cart and was intended for room service, resulting in the delay. Both the Activity Director and Licensed Vocational Nurse acknowledged that meals should be served in an organized manner to ensure no resident is left out, and that this incident was a dignity issue. The resident involved had a history of depression and diabetes mellitus and was documented as mentally capable of understanding her surroundings. The Director of Nursing stated that staff are expected to serve trays simultaneously to all residents at a table and follow a system to prevent such oversights. The facility's policy on dignity and privacy requires all residents to be treated with kindness, dignity, and respect. The failure to serve the meal in a timely and equitable manner led to the resident feeling forgotten and potentially affected her psychosocial well-being.
Failure to Maintain Homelike Environment Due to Peeling Paint
Penalty
Summary
Surveyors observed that the facility failed to maintain a comfortable and homelike environment for residents, as evidenced by the presence of peeled paint in multiple resident rooms. Specifically, peeled paint was noted on the wall at the right side of one resident's bed and on the side of the wall next to another resident's bed. Additionally, areas of peeled paint were observed at the bathroom door frame in a resident room. These environmental deficiencies were directly observed during multiple walkthroughs by surveyors and confirmed during a concurrent observation with the Maintenance Supervisor. Interviews with the Maintenance Supervisor and the Administrator confirmed that maintaining painted, clean, and smooth walls is part of their responsibility to ensure a homelike environment. The facility's policy on providing a homelike environment was also reviewed, which emphasizes the importance of maintaining areas that reflect a homelike atmosphere. The failure to address the peeling paint in resident rooms and bathrooms resulted in an environment that did not meet the facility's stated standards for comfort and homelikeness.
Inaccurate MDS Coding for Resident with Hearing Loss
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment for a resident with hearing loss was accurately coded. The resident was admitted with a diagnosis of right ear hearing loss and used a hearing aid in the left ear. Multiple records, including the inventory sheet and social service summary, documented the presence and use of a left hearing aid and noted moderate hearing difficulty. However, the MDS assessment incorrectly indicated that the resident was not using a hearing aid and had adequate hearing ability. During interviews, both the MDS Nurse and the Director of Nursing acknowledged that the MDS assessment did not accurately reflect the resident's actual hearing status and should have been coded as moderately impaired with hearing. The facility's policy and the Resident Assessment Instrument (RAI) manual require that assessments accurately reflect the resident's status, which was not followed in this instance.
Failure to Provide Audiology Consultation for Resident with Hearing Loss
Penalty
Summary
The facility failed to provide an audiology consultation for a resident with documented hearing loss. Upon observation and interview, the resident was noted to have difficulty hearing staff even while using a left hearing aid, which was reported as not functioning properly. Multiple staff members, including a CNA, RN, Social Service Director, and DON, acknowledged the resident's ongoing hearing difficulties and the need for an audiology referral. The resident's records, including the admission record, order summary, care plan, and social service summary, all indicated hearing impairment and the need for audiology evaluation, yet no evidence was found that such a referral or evaluation was completed. The facility's policy required social services to coordinate and monitor audiology evaluations, but this process was not followed for the resident in question. The lack of action resulted in the resident continuing to experience hearing difficulties without appropriate intervention, as documented in both staff interviews and record reviews. The deficiency was identified through direct observation, interviews with staff, and review of the resident's medical and care records.
Failure to Provide Timely Dental Consultation and Services
Penalty
Summary
The facility failed to ensure that a dental consultation was provided for a resident who was reviewed for dental care. During an observation and interview, the resident was noted to have missing upper and lower teeth and expressed a desire for dentures, stating he had not been seen by a dentist and had difficulty chewing solid food. Record review showed a physician's order for a dental consult with follow-up treatment as needed, and a previous dental assessment indicated multiple missing teeth and root tips with treatment recommended. The resident was found to be cognitively intact and capable of understanding his care needs. Interviews with facility staff, including the Social Service Director and Director of Nursing, confirmed that the resident should have been referred for dental services to address his needs. The facility dentist also stated that he would have seen the resident promptly if a referral had been made. Facility policy requires social services to coordinate and monitor dental evaluations, but this process was not followed for the resident, resulting in the lack of necessary dental care.
Failure to Provide Assistive Eating Equipment for Resident with Parkinson's Disease
Penalty
Summary
A deficiency occurred when the facility failed to provide necessary assistive eating equipment, specifically a plate divider, to a resident with Parkinson's disease who required such adaptive devices during mealtime. During observation, the resident was seen struggling to keep food on her plate, resulting in food falling onto the floor. The resident expressed difficulty with the provided utensils, and both the LVN and DON acknowledged that a plate guard should have been supplied to assist with eating. The resident was on a mechanical soft, no added salt diet and was mentally capable of understanding her needs. Record review confirmed the resident's diagnosis and dietary requirements, and interviews with facility staff revealed that the resident had not been evaluated or referred for adaptive equipment as outlined in the facility's policy. The Director of Rehabilitation stated that staff should have referred the resident for an evaluation to determine the need for adaptive devices, and the facility's policy indicated that adaptive equipment should be provided as needed, with occupational therapy involvement recommended for assessment.
Deficiencies in Dietary Services and Food Preparation
Penalty
Summary
The facility failed to ensure that dietary staff followed proper cleaning procedures for food preparation surfaces and equipment, which could potentially lead to foodborne illness for all 64 sampled residents. Observations and interviews revealed that food service workers, including CK 1, CK 2, and CK 3, used sanitizer to clean prep table surfaces and stationary equipment, contrary to the facility's procedure that required washing with a warm detergent solution, rinsing with clear water, and then sanitizing. The Dietary Supervisor confirmed the use of sanitizer, and the facility's policy emphasized the importance of sanitation training for employees. Additionally, the facility did not adhere to prescribed dietary requirements for residents on pureed diets. CK 1 served chunky pasta to 10 residents who required a pureed diet, posing risks of aspiration and choking. A test tray conducted with the Dietary Supervisor confirmed the presence of chunks in the pureed noodles, and the Registered Dietitian stated that pureed diets should be smooth with no chunks. The job description for cooks included preparing food for therapeutic diets according to planned menus and standardized recipes, which was not followed in this instance.
Improper Storage of Medications in EKITs
Penalty
Summary
The facility failed to ensure that medications in emergency medication supply containers (EKITs) were stored safely and organized properly. During an inspection, it was observed that two EKITs contained multiple different unit-dose medications mixed together in each compartment. Specifically, one EKIT labeled Nonantibiotic EKIT #1 (A-L) had 13 compartments for 48 different medications, and the other labeled Nonantibiotic EKIT #2 (M-W) had 17 compartments for 40 different medications. Medications were placed alphabetically, and some compartments contained medications with similar-sounding names, such as citalopram, carvedilol, and carbidopa/levodopa, which were stored together. The Consultant Pharmacist confirmed that medications in EKITs should be compartmentalized, with each medication stored separately to ensure safety and accuracy in medication administration. The facility's policy on medication storage emphasized that medications should be stored safely and free of clutter. Additionally, guidelines from the Institute for Safe Medication Practices (ISMP) recommend storing medications with look-alike and sound-alike names in separate locations to prevent errors. The facility's failure to adhere to these guidelines and policies increased the potential for medication errors and delays in administering the correct medication.
Inappropriate Food Texture Served to Residents on Pureed Diet
Penalty
Summary
The facility failed to provide the appropriate food texture for 10 residents who were on a physician-prescribed pureed diet. During a meal service on May 8, 2024, these residents were served chunky noodles instead of the required smooth consistency. This was confirmed through a test tray conducted by the surveyor and the Dietary Supervisor, who both observed that the pureed noodles contained chunks and did not meet the necessary smooth consistency. The Dietary Supervisor acknowledged the potential risks associated with serving chunky noodles to residents on a pureed diet, including choking and aspiration. Further interviews and document reviews supported these findings. A Registered Dietitian confirmed that a pureed diet should be smooth with no chunks, emphasizing the risks of choking and aspiration for residents with difficulty chewing and swallowing. The review of the Physician Prescribed Diet Orders confirmed that the affected residents were indeed on a pureed diet. Additionally, the facility's recipe for pureed starches and the Regular Pureed Diet Definition from the Diet Menu both specified that the texture should be smooth and moist, aligning with the requirements that were not met during the observed meal service.
Sanitation and Maintenance Deficiencies in Kitchen
Penalty
Summary
The facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen, as observed during a survey. Food service workers did not adhere to the facility's cleaning procedures for food preparation surfaces and stationary equipment. Specifically, the staff used sanitizer alone to clean these areas, contrary to the proper procedure of washing, rinsing, and sanitizing. This deviation from protocol was confirmed through interviews with the dietary staff and registered dietitians, who acknowledged the risk of cross-contamination due to improper cleaning practices. Additionally, the facility did not maintain proper hygiene standards for kitchen staff, as evidenced by a cook not covering his mustache during meal preparation. This was against the facility's dress code policy, which requires facial hair to be restrained to prevent cross-contamination. The dietary supervisor and registered dietitian confirmed that the cook should have adhered to this policy. The physical condition of the kitchen also contributed to the deficiency. Observations revealed cracked tiles, missing grout, peeling paint, and rusted storage shelves, all of which hindered effective cleaning and sanitation. Furthermore, there was a buildup of grease on the fire hoods, grime inside the microwave, dust on the grid divider, and buildup on the ice machine pipes. These conditions were acknowledged by the dietary supervisor and registered dietitian, who emphasized the need for smooth, cleanable surfaces to prevent contamination.
Failure to Include Advance Directive in Resident's Medical Record
Penalty
Summary
The facility failed to ensure that a copy of a resident's Advance Directive (AD) was available and accessible in the resident's medical record. This deficiency was identified during a review of the records for a resident who was admitted to the facility and had indicated the existence of an AD. Despite the resident's acknowledgment of having an AD, there was no documented evidence of the AD being included in the medical record. During an interview with the Social Service Director (SSD), it was confirmed that the SSD was responsible for the formulation and follow-up of ADs. The SSD acknowledged that the resident's AD should have been obtained and placed in the medical record, but it was not available. The facility's policy, dated December 2023, required that a copy of any advance directives be included in the medical records, but this procedure was not followed in this instance.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor a resident's food preferences, specifically for milk and soup, during a lunch meal. On May 7, 2024, Resident 39 did not receive the 4 oz. of milk and pureed soup as indicated on their Meal Tray Ticket, which was based on the resident's diet physician order and food preferences. This was confirmed during a dining room observation and interview with both the resident and a Certified Nurse Assistant (CNA). The Dietary Supervisor (DTR) acknowledged that the resident did not receive the specified items and noted that no alternative was offered when soup was unavailable. The Dietary Supervisor explained that residents' food preferences are updated regularly and entered into a tray card system to generate meal tray tickets. The Registered Dietitian emphasized the importance of honoring food preferences to prevent unplanned weight loss. A review of the facility's policies indicated that food preferences should be adhered to within reason, and meal trays should be checked to ensure nothing is missing. Despite these policies, the failure to provide the requested items to Resident 39 was a clear deviation from the established procedures.
Failure to Follow Physician's Dietary Orders
Penalty
Summary
The facility failed to adhere to physician orders for a resident who was on a pureed diet and required a specific oral nutrition supplement. During a dining observation, the resident was served a regular texture salad instead of the prescribed pureed diet. This was confirmed by the Activities Supervisor, Activities Assistant, Dietary Supervisor, Director of Staff Development, and a Registered Dietitian, all of whom acknowledged the error and the potential risk of aspiration and choking due to the resident's difficulty in chewing regular texture foods. The facility's policies on diet orders, menu planning, and meal service were reviewed, indicating that meals should meet the nutritional needs of residents as per physician orders. Additionally, the resident was given a Boost Glucose Control supplement instead of the prescribed Boost, which contained fewer calories than ordered. This discrepancy was noted during a dining room observation and confirmed by the Dietary Supervisor and Director of Nursing. The facility's policy stated that diet orders prescribed by the physician should be provided accurately, but the resident received a supplement with fewer calories, potentially affecting their ability to gain weight. The facility's failure to follow the physician's dietary and supplement orders was documented, highlighting the importance of adhering to prescribed nutritional plans.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during wound care for a resident with a pressure injury. During an observation, the Treatment Nurse (TN) did not change gloves or perform hand hygiene after removing a soiled wound dressing and before cleaning the resident's wound with normal saline. This lapse in protocol was acknowledged by the TN during an interview, where he admitted to not following good infection control practices. The resident involved, identified as Resident 64, was admitted with a Stage 4 pressure ulcer in the sacral region and a local infection of the skin and subcutaneous tissue. The facility's policy on wound treatment, dated January 2024, clearly outlines the steps for proper wound care, including hand hygiene and glove changes, which were not followed in this instance. The Director of Nursing confirmed that the TN should have adhered to these procedures to prevent cross-contamination and infection.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Riverside
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arlington Gardens Care Center | 2.7 mi | ★★★★★ | 20 | 1 |
| Riverside Postacute Care | 2.7 mi | — | 93 | 2 |
| Citrus Grove Post Acute | 2.9 mi | ★★★★★ | 20 | 0 |
| Riverwalk Post Acute | 3.1 mi | ★★★★★ | 21 | 0 |
| Alta Vista Healthcare & Wellness Centre | 3.5 mi | ★★★★★ | 6 | 0 |
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