Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Palms Nursing & Rehabilitation during CMS and state inspections, most recent first.
A resident with severe dementia and a history of multiple falls did not have a person-centered, comprehensive care plan with measurable objectives to address fall prevention. The care plan included only general interventions and lacked individualized strategies, despite the resident's repeated falls and cognitive impairment. Staff and leadership acknowledged the absence of specific interventions and the challenges in providing adequate supervision.
A CNA made inappropriate and ridiculing comments to a resident with complex medical needs during peri-care, failing to protect the resident's right to be free from verbal abuse. The incident was witnessed on video, reported by the resident and family, and confirmed through staff interviews and record review.
A resident with dementia, stroke, aphasia, and AV block, who was dependent on staff for daily care and had severe cognitive impairment, did not have a comprehensive care plan in place. Staff were unable to locate any care plan documentation in the chart or electronic records, and interviews revealed confusion about responsibility for care plan development following the absence of an MDS nurse.
Two residents did not have their care plans reviewed or updated after comprehensive, quarterly, or change of condition assessments. One resident's care plan was not revised to reflect a transition to hospice care and new opioid orders, while another's care plan had not been updated in over a year and did not address new diagnoses or medications. Staff interviews revealed confusion about responsibility for care plan updates, and facility policy requiring timely care plan revisions was not followed.
A CNA verbally abused a cognitively impaired male resident with dementia and communication deficits by yelling at him in a public hallway, telling him to do things himself and refusing assistance. The resident showed signs of emotional distress and confirmed feeling sad and embarrassed due to the CNA's language and tone. Staff interviews and facility records indicated the CNA had a history of being loud and had previously been told to moderate his behavior, but no prior abuse had been reported.
A facility failed to immediately report and investigate an alleged abuse incident involving a cognitively impaired resident and two other residents. Despite staff awareness of possible inappropriate behavior and conflicting accounts, no physical assessment or formal investigation was conducted, and the incident was not reported to state authorities as required by law and facility policy.
A facility failed to thoroughly investigate and document an alleged abuse incident involving multiple residents with cognitive and mental health impairments. Staff did not perform required assessments or complete incident reports, and interviews revealed that the necessary investigative steps were not followed according to facility policy.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
The facility did not complete or document required Quarterly Elopement Assessments for multiple residents after the previous MDS nurse left and no staff assumed responsibility for tracking due dates, resulting in incomplete medical records and lack of proper resident evaluation.
A resident with depression and intact cognition was addressed in a stern and disrespectful manner by an RN during a post-fall assessment, as captured on surveillance video. Facility leadership confirmed the interaction did not uphold the resident's right to dignity and respect, and the care plan lacked related guidance.
A facility failed to thoroughly investigate missing Clonazepam tablets for a resident with multiple chronic conditions. Only the two LVNs involved were interviewed, while neither the resident, her responsible party, nor other potentially affected residents were included in the investigation. Medication counts were not properly verified, and the facility did not follow its own policy for interviewing all potential witnesses.
A resident identified as at risk for falls was moved from the floor to her bed by an LVN after an unwitnessed fall without first having her vital signs or neurological status checked, contrary to facility policy. Interviews with staff confirmed that the required assessment was not performed prior to moving the resident.
A facility failed to accurately acquire, receive, dispense, and administer a controlled medication for a resident, resulting in 11 missing tablets of Clonazepam. The medication count process was not properly followed, as staff did not consistently verify the physical count together. The investigation was limited to interviewing and drug testing the two nurses involved, without interviewing the resident, responsible party, or other residents at the time.
A resident with multiple complex diagnoses was admitted without medications, personal items, or adequate behavioral information from the previous facility. After exhibiting sexually inappropriate behavior, the facility determined it could not meet the resident's needs and attempted to return the resident the same day without proper coordination or documentation. The original facility refused readmission, resulting in the resident being sent to the hospital due to lack of placement.
A resident with neurological deficits and mobility issues was transferred from bed to wheelchair without the use of a gait belt by a CNA, despite facility policies requiring it. The CNA used the resident's affected arm for support, leading to a struggle during the transfer. The CNA admitted to not having a gait belt on hand, and facility leadership confirmed the oversight, highlighting the risk of potential falls.
A resident with dementia and mobility dependence suffered a dislocated shoulder and broken elbow due to inadequate supervision and handling. The resident reported being improperly handled by an unfamiliar CNA, leading to the injury. Despite staff following protocol and an internal investigation, the cause of the injury remained inconclusive.
A facility failed to include a resident's preferences and activities in their care plan, despite the resident's ability to sign in and out for meals and appointments. The resident, with intact cognitive function and a history of mental health issues, was not provided a care plan reflecting her needs and preferences, as confirmed by interviews with facility staff.
A facility failed to conduct a required PASRR evaluation for a resident with multiple mental health diagnoses, including Alzheimer's and mood disorders. Staff interviews revealed a lack of awareness and understanding of the PASRR process, leading to the oversight. The MDS nurse and coordinator did not complete a Level II evaluation due to misinterpretations of the screening process, and the DON acknowledged the need for system improvements.
A LTC facility failed to update care plans for three residents, leading to discrepancies in their medical records. One resident's care plan did not reflect her current code status, another's did not show the discontinuation of insulin, and a third's was outdated regarding wound care and self-catheterization. These oversights indicate a lack of communication and coordination among the care team.
The facility's kitchen and nutrition rooms were found to have multiple sanitation and food safety deficiencies, including unsanitary conditions, improper food storage, and inadequate staff hygiene practices. Observations revealed issues such as gnats, mold-like substances, and improperly stored food items. Staff interviews indicated a lack of training and awareness of food safety protocols, contributing to the risk of foodborne illnesses.
The facility failed to maintain an effective pest control program in the kitchen, with gnats and a foul odor present in the dish room, and a gaping hole allowing potential rodent entry. The FSM was unaware of the structural issue, and the ADM and MS lacked documentation and awareness of pest control measures. Pest sightings were noted in logs, but invoices were not provided, indicating a failure to adhere to the facility's kitchen policy on pest prevention.
The facility failed to provide written notification of transfer or discharge to two residents, their representatives, and the Ombudsman. One resident was transferred to the ER for low saturation and shortness of breath, while another was hospitalized after a fall. The ADON confirmed that notifications were made verbally by phone, contrary to the facility's policy requiring written notices.
A resident with new diagnoses of serious mental disorders was not referred for a PASRR Level II screening, as required. The facility's MDS coordinator was unaware of the need to update PASRR screenings for significant changes in condition. The DON recognized the deficiency in care planning and PASRR processes, noting the absence of measures to ensure PASRR accuracy during her tenure.
A resident with severe cognitive impairment and multiple medical conditions had her urinary catheter drainage bag repeatedly observed touching the floor, contrary to facility policy. Despite staff awareness of proper procedures, the deficiency persisted, increasing the risk of urinary tract infections.
A facility failed to ensure safe storage of medications in a medication cart, where disinfectant wipes were stored with resident medications, and personal drink items were found. RN A acknowledged the risk of cross-contamination, and the DON confirmed the need for separate storage of chemicals and personal items. The facility's policy requires orderly storage of drugs, but this was not followed, leading to the deficiency.
The facility failed to maintain essential kitchen equipment, including a refrigerator, freezers, and an ice machine, in safe operating condition. Observations revealed a leaking sink, a dangerous electrical box, and contaminated ice machine. The FSM reported these issues to maintenance, but no action was taken. The MS was unaware of several problems and believed the equipment was functioning properly. Maintenance documentation was requested but not provided.
The facility failed to secure a storage room on hall 2400 containing mouthwash with alcohol and shower rooms on halls 200 and 2200 with disinfectants left out. Staff interviews confirmed these areas should have been locked to prevent resident access to hazardous items.
A resident was verbally abused by a staff member, SA, during a confrontation about patio cleaning during a smoke break. Witnesses confirmed SA's use of derogatory language, but the facility's investigation was inconclusive, and SA returned to work. The incident caused the resident significant distress, and other residents reported similar behavior from SA. The facility's response was inadequate, failing to ensure a safe environment as per their abuse prevention and resident rights policies.
A resident experienced verbal abuse from a smoking attendant, who used profane language during a smoking break. Despite facility policies requiring reporting to law enforcement, the incident was not reported, and the attendant was allowed to return to work in a different role. The resident, with no cognitive impairment, felt anxious and unprotected, and the facility's investigation was deemed inconclusive.
A facility failed to securely store a resident's discontinued medication, leaving it accessible in a clear bin on the ADON's office door. The medication, Azithromycin, was meant for a resident with dementia and other health issues. Staff interviews revealed that the medication was mistakenly left in the bin, which was intended for empty blister packs only, violating the facility's policy requiring medications to be stored in a locked box.
A CNA failed to perform proper hand hygiene and under foreskin cleansing during the care of a resident with severe cognitive impairment and a history of UTIs. The CNA did not wash hands after touching contaminated surfaces or use ABHR during glove changes, and did not retract the foreskin for cleaning, contrary to facility guidelines.
Failure to Develop and Implement Individualized, Measurable Fall Prevention Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered, comprehensive care plan with measurable objectives and timeframes to address the needs of a resident with severe dementia and a history of falls. The resident, who was admitted with a primary diagnosis of unspecified dementia and demonstrated severe mental impairment, required assistance with activities of daily living and had a history of multiple falls within a three-month period. The care plan identified the resident as a fall risk and listed general interventions such as keeping the bed in a low position, ensuring the call light was within reach, and maintaining a clutter-free environment. However, the care plan did not include individualized or measurable objectives specifically tailored to prevent falls for this resident. Record review and staff interviews revealed that the resident was mobile using a wheelchair and walker, and was independent with transfers but lacked personal safety awareness due to cognitive impairment. Incident reports documented a witnessed fall from the wheelchair while the resident was attempting to pick up a blanket, resulting in hematomas and a subsequent emergency room evaluation. Staff interviews indicated that the resident was not redirectable, and while staff attempted to supervise and redirect her, they acknowledged the lack of specific interventions in the care plan to address her fall risk. Staff also reported that 1:1 supervision was not feasible due to staffing limitations. Further interviews with facility leadership and the hospice case manager confirmed ongoing challenges in identifying effective interventions to prevent falls for the resident. The Director of Nursing and Administrator acknowledged the care plan's lack of specificity and measurable objectives, and noted unsuccessful attempts to find alternative placement for the resident. Despite ongoing communication with the resident's family and hospice provider, the facility had not developed or implemented a comprehensive, individualized care plan to address the resident's fall risk.
Failure to Protect Resident from Verbal Abuse During Personal Care
Penalty
Summary
A certified nursing assistant (CNA) made an insulting and ridiculing comment toward a resident during personal care, failing to protect the resident's right to be free from verbal abuse. The resident, a female with multiple complex medical conditions including neuromuscular dysfunction of the bladder, obstructive uropathy, metabolic encephalopathy, diabetes mellitus, and paraplegia, was bedbound and dependent on staff for all activities of daily living and toileting. The resident had a history of behavioral symptoms, including making false allegations and threats toward staff, but was assessed as having intact cognition. During an episode of peri-care, the CNA was observed on video making a comment to the resident, stating, "Yeah, we know what you like," after the resident confirmed she was clean. The resident immediately expressed that the comment was inappropriate and uncalled for. The CNA then raised her voice and continued to make remarks about the resident's requests for cleaning, indicating frustration and a lack of professionalism. The incident was reported by the resident and her family, and video evidence was provided to facility leadership. Interviews with facility staff revealed uncertainty about whether the CNA's comments constituted verbal abuse, with some staff suggesting the context was unclear or that the relationship between the CNA and the resident involved joking. However, the CNA herself acknowledged that her comments were inappropriate and admitted to being frustrated with the resident's repeated requests for cleaning. The incident was reported to the state, and the CNA was suspended pending investigation. The facility's abuse prevention policy states that residents have the right to be free from all forms of abuse, including verbal and mental abuse.
Failure to Develop and Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident with multiple complex medical conditions, including unspecified dementia, cerebral infarction, aphasia, and atrioventricular block. Despite the resident's significant cognitive and functional impairments, including severely impaired decision-making skills, memory problems, and dependence on staff for daily activities such as oral hygiene, toileting, showering, and personal hygiene, there was no care plan available in either the electronic or paper chart. Staff interviews revealed confusion and lack of clarity regarding responsibility for care plan development and updates, particularly following the absence of an MDS nurse. The social worker, ADON, and DON all indicated uncertainty about whether a care plan had ever been completed for the resident, and after an extensive search, no documentation of a care plan or care plan meeting could be found. Facility policy requires the development and implementation of a comprehensive, person-centered care plan with measurable objectives and timetables for each resident, based on thorough assessment. However, in this case, the required care plan was not present, and staff were unable to confirm its existence or completion. This deficiency was identified through interviews and record reviews, which confirmed the absence of the care plan and highlighted gaps in the facility's processes for ensuring timely and consistent care planning for residents with complex needs.
Failure to Review and Revise Care Plans After Assessments and Changes in Condition
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, including both comprehensive and quarterly review assessments, as well as change of condition assessments. For two residents whose care plans were reviewed, the care plans did not reflect current diagnoses, treatments, or needs. One resident, with diagnoses including unspecified dementia and COPD, was admitted to hospice care and prescribed morphine for pain management, but the care plan was not updated to include these significant changes. The care plan for this resident had not been reviewed or revised since several months prior to the change in condition and new orders. Another resident, with diagnoses including unspecified dementia, type 2 diabetes, coronary artery disease, hypertension, anxiety, and depression, had a quarterly MDS assessment indicating new or ongoing conditions and medications, such as hypertension and a new order for amlodipine. However, the care plan for this resident had not been reviewed, revised, or edited in over a year and did not address the current diagnosis of hypertension or the associated medication. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for updating care plans, especially in the absence of a dedicated MDS nurse. The social worker and ADON were unsure who was responsible for care plan updates, and the regional MDS nurse confirmed that care plans had not been reviewed or updated as required. Facility policy required care plans to be developed and revised based on ongoing assessments and changes in resident condition, but this was not followed for the residents reviewed.
Verbal Abuse of Cognitively Impaired Resident by CNA
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) verbally abused a male resident with vascular dementia, major depressive disorder, and generalized anxiety disorder. The resident, who had severe cognitive impairment and required assistance with activities of daily living, was observed by a surveyor as the CNA yelled at him in the hallway, telling him to do things himself and stating that no one else would help him. The CNA continued to raise his voice, disregarding a registered nurse's (RN) intervention to lower his tone, and justified his behavior as 'tough love.' The resident was observed holding his coffee cup, looking at staff, and displaying signs of emotional distress, such as looking down and having watery eyes. When interviewed, the resident confirmed through gestures and limited speech that the CNA's language and tone made him feel sad and embarrassed. Staff interviews revealed that the CNA had a history of being loud and had previously been told to tone down his behavior, but there were no prior reports or grievances of abuse from residents or staff. Other residents interviewed denied experiencing or witnessing similar behavior from the CNA. Facility records and staff interviews confirmed that the CNA's actions constituted verbal abuse, as defined by the facility's policies and resident rights statements. The incident was witnessed by multiple staff members, and the facility's documentation indicated that the CNA's conduct was not in accordance with the expected standards of respect and dignity for residents. The resident's care plan and medical history highlighted his vulnerability due to cognitive and communication deficits, further emphasizing the impact of the CNA's actions.
Failure to Timely Report and Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, and/or mistreatment were reported immediately, as required by law and facility policy. Specifically, an incident involving a resident with severe cognitive impairment and other residents was not reported to the state or investigated further, despite multiple staff being aware of allegations of possible sexual abuse or inappropriate behavior. The incident was not documented in the facility's incident and accident reports, and no formal investigation was initiated at the time of the event. The resident at the center of the incident had a history of dementia, cognitive communication deficit, bipolar disorder, alcohol-induced persisting dementia, and depression, with a severely impaired BIMS score indicating significant cognitive impairment. On the night in question, staff observed unusual behavior: one resident refused to enter his room, reporting hearing noises and expressing discomfort, while another was found standing in the dark with his hands over his private area. Staff reported the situation to the charge nurse, who then notified the DON and Administrator. However, neither the charge nurse nor other staff performed a physical assessment or thorough investigation of the residents involved at the time. Interviews revealed that staff and residents provided conflicting accounts, with some staff expressing concern that the incident should have been investigated as possible abuse, especially given the cognitive status of the resident involved. Despite these concerns and the facility's own policies requiring immediate reporting and investigation of such allegations, the DON and Administrator decided not to report the incident to the state, citing denials from the residents involved. The lack of timely reporting, assessment, and documentation constituted a failure to follow both regulatory requirements and the facility's abuse prevention and reporting policies.
Failure to Investigate and Document Alleged Abuse Incident
Penalty
Summary
The facility failed to thoroughly investigate and respond to an allegation of possible abuse, neglect, or mistreatment involving multiple residents. On the night in question, a CNA observed one resident sitting outside his room, expressing discomfort about entering due to noises and activities occurring inside. Upon checking, the CNA found two other residents alone in the dark room, with one standing against the wall covering his private area. The CNA reported this to the charge nurse, who did not perform a physical or environmental assessment of the residents or the room, nor did she further investigate the situation before escalating the matter to the DON and Administrator. The DON and Administrator arrived at the facility and interviewed the residents involved, all of whom denied any inappropriate behavior or sexual activity. However, no incident report was completed for the event, and there was no documentation of a thorough investigation, including physical assessments or interviews with all potentially involved parties. Staff interviews revealed that the charge nurse did not assess the residents or the environment, and the DON later acknowledged that a complete investigation, including required documentation and assessments, was not conducted. Additionally, the facility's own policies required prompt and thorough investigation and reporting of all alleged violations, which was not followed in this case. The residents involved had significant cognitive and mental health diagnoses, with at least one resident having severely impaired cognition and another with a history of mental illness and behavioral issues. Staff statements indicated uncertainty about the capacity of one resident to consent to sexual activity, and there were conflicting accounts regarding what was heard or observed. Despite these complexities, the facility did not ensure that all required investigative steps were taken, nor did it document the incident or protect residents as outlined in its policies.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Complete and Document Quarterly Elopement Assessments
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with professional standards for five residents, specifically by not completing required Quarterly Elopement Assessments since January 2025. Record review showed that none of the sampled residents had these assessments completed after 01/16/2025. Interviews with staff revealed that the previous MDS nurse had been responsible for creating a calendar to track when these assessments were due, but after her termination, the new MDS nurse did not assume this responsibility, stating it was not part of her job. As a result, neither the charge nurses nor the ADONs created the calendar, and the assessments were not performed. Further interviews with the ADON, MDS nurse, and DON confirmed that the lack of a tracking system led to the omission of the required assessments. The DON acknowledged that nursing staff were supposed to manage the assessment schedule but had not done so, resulting in incomplete documentation. The facility did not have a specific policy regarding Quarterly Elopement Assessments, as confirmed by the Administrator.
Failure to Maintain Resident Dignity During Post-Fall Assessment
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to treat a resident with dignity and respect during a post-fall assessment. The incident involved a female resident with a diagnosis of depression and an intact cognitive status, as indicated by a BIMS score of 13. After an unwitnessed fall in her room, the RN addressed the resident in a stern tone, asking, 'What is wrong with you?' and 'Do you want to break something?' while the resident was still on the floor. This interaction was captured on surveillance video and confirmed through observation and interviews. The resident's comprehensive care plan did not contain information related to dignity or respectful treatment. Interviews with facility leadership, including the ADON, ADM, and DON, confirmed that the resident was not treated with dignity, respect, consideration, or courtesy during the incident. The facility's admission packet also states that residents have the right to be treated with dignity, courtesy, consideration, and respect.
Failure to Thoroughly Investigate Missing Controlled Medication
Penalty
Summary
The facility failed to thoroughly investigate an alleged violation involving missing controlled medication for a resident with end stage renal disease, anxiety, type 2 diabetes, and depression. The incident involved an incorrect count of Clonazepam, with 11 tablets missing, discovered during a routine medication count by two LVNs. Both nurses involved were interviewed, drug tested, and suspended pending investigation, but no other staff, residents, or responsible parties were interviewed at the time of the incident. Despite the resident having intact cognition, as indicated by a BIMS score of 15, neither the resident nor her responsible party was notified or interviewed regarding the missing medication. The facility's investigation did not include interviews with other residents who might have been involved or affected, nor did it verify with the resident whether any doses were missed or if there were any changes in her condition. The facility's own policy required interviewing all potential witnesses and identifying the alleged victim, but these steps were not followed during the initial investigation. Observations also revealed that medication counts were not being properly verified, with one staff member counting while the other only checked the sheet, rather than both verifying the physical count and the documentation. This practice was acknowledged by staff as a potential concern for medication security. The lack of a comprehensive investigation and failure to follow established procedures placed residents at risk of not having their allegations of abuse, neglect, or misappropriation thoroughly or timely investigated.
Failure to Follow Post-Fall Assessment Policy
Penalty
Summary
A deficiency occurred when a resident with diagnoses of depression and muscle wasting, and identified as being at risk for falls, did not receive care in accordance with the facility's post-fall assessment policy. After an unwitnessed fall in her room, surveillance video showed that an LVN entered, briefly checked on the resident, and then supervised her movement from the floor to her bed without first performing vital signs or neurological status checks. The resident's care plan included multiple fall prevention interventions, but the required post-fall assessment was not completed prior to moving her. Interviews with the ADON, LVN, and DON confirmed that the facility's policy requires a licensed nurse to evaluate a resident's condition, including vital signs and neurological status, before moving them after a fall. The LVN involved acknowledged not following this protocol and stated the importance of such assessments to prevent further harm. The facility's policy, last revised in 2014, specifically directs that residents should not be moved until this evaluation is completed, unless absolutely necessary. This protocol was not followed in the incident involving the resident.
Failure to Accurately Account for and Investigate Missing Controlled Medication
Penalty
Summary
The facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for a resident, specifically regarding the controlled medication Clonazepam 0.125 mg. An incorrect narcotic count was discovered during a shift change, revealing that 11 tablets were missing from the resident's supply. The discrepancy was identified when the oncoming and off-going nurses counted the medication together, and both denied taking the pills. The count had been correct the previous night, and the missing tablets were never recovered. The medication administration records confirmed the loss, showing a decrease in the tablet count between the two shifts. Observations of the medication counting process revealed that the off-going nurse typically only verified the count sheet rather than directly observing the physical count of medications, while the oncoming staff performed the count. This practice did not ensure both parties verified the actual medication count, and the process was not consistently followed as intended. The nurse involved stated she had not been instructed to perform the count differently and acknowledged that not verifying the count could lead to missing or stolen medications. Additionally, the nurse did not perform a count immediately after administering controlled medications during her shift, instead waiting until the end of the shift. The investigation into the missing medication was limited to interviewing and drug testing the two nurses involved, with no interviews conducted with the resident, her responsible party, or other residents at the time of the incident. The resident later confirmed she was not interviewed about the missing medication and denied missing any doses or experiencing increased anxiety. Facility leadership acknowledged that no other staff or residents were interviewed during the initial investigation, and the responsible party was not notified until several months later.
Failure to Ensure Safe and Orderly Discharge
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for a resident who was admitted with multiple diagnoses, including Autistic Disorder, Epilepsy, Dysphasia, and Cognitive Communication Deficit Disorder. Upon admission, the resident arrived without medications, a medication list, personal items, and was soiled. The facility did not receive adequate communication from the discharging facility regarding the resident's behavioral issues, specifically sexually inappropriate behaviors, which were not documented on the face sheet or communicated prior to transfer. After admission, the resident exhibited sexually inappropriate behavior toward female staff, which the facility was unprepared to manage. The Director of Nursing and Administrator determined they could not meet the resident's needs and decided to return the resident to the original facility. The process was not coordinated, and the original facility refused to readmit the resident, leading to involvement from the police and Adult Protective Services. The resident ultimately was sent to the hospital due to lack of placement. The facility's actions did not follow their own Transfer and Discharge policy, which requires written notice, documentation of the reason for transfer or discharge, and communication with the resident, their representative, and the Long-Term Care Ombudsman. The discharge was rushed, lacked proper documentation, and failed to ensure the resident's safety and continuity of care, resulting in the resident being left without appropriate placement.
Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
The facility failed to ensure adequate supervision and use of assistive devices to prevent accidents for a resident with significant medical conditions. The resident, a male with a history of muscle wasting, atrophy, and neurological deficits due to a stroke, required partial to moderate assistance for transfers. Despite these needs, a CNA did not use a gait belt during a transfer from the bed to a wheelchair, which could have compromised the resident's safety. During the transfer, the CNA assisted the resident by holding his left arm, which was affected by hemiplegia, instead of using a gait belt. The resident struggled and staggered during the pivot from the bed to the wheelchair, indicating a lack of stability and balance. The CNA admitted to not having a gait belt on her person, as it was left in her locker, and acknowledged the potential risk of a fall during the transfer. Interviews with the DON and ADON revealed that the CNA should have used a gait belt as a safety precaution, and it was standard practice for CNAs to carry a gait belt. The resident's care plan indicated a need for assistance with transfers, contradicting the ADON's initial statement of the resident's independence. The facility's policies and training materials emphasized the importance of using gait belts for safe resident transfers, which was not adhered to in this instance.
Resident Injury Due to Inadequate Supervision and Handling
Penalty
Summary
The facility failed to ensure adequate supervision and prevent accidents for a resident who suffered a dislocated shoulder and a broken elbow. The resident, who was admitted with diagnoses including vascular dementia and osteoarthritis, was completely dependent on staff for mobility and had impaired cognitive abilities. The care plan indicated the resident was bed-bound and required assistance from two staff members for transfers using a mechanical lift. On the day of the incident, the resident was sent to the hospital for pain in her left arm, where a dislocated shoulder and a later identified broken elbow were diagnosed. Interviews revealed that the resident complained of pain and mentioned being hurt by someone, but could not provide specifics due to her cognitive impairments. The Nurse Practitioner was notified and ordered acetaminophen and an x-ray, but the x-ray was delayed due to the unavailability of a technician. The resident was eventually sent to the hospital for evaluation. The facility conducted an internal investigation, suspending three staff members pending the outcome. Witness statements indicated that repositioning in the shower was completed without issues, and staff demonstrated proper transfer techniques during observations. However, the resident described an incident where she was improperly handled by an unfamiliar CNA, which she claimed caused her injury. The Director of Nurses and the Administrator acknowledged the incident and the delay in obtaining an x-ray, but the investigation did not yield a conclusive finding regarding the cause of the injury.
Failure to Include Resident's Preferences in Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan for a resident, which included the resident's preferences to leave the building and the necessary actions or long-term goals to meet the resident's needs. The resident, who was admitted with major depressive disorder, schizophrenia, and acute gastritis, had a Brief Interview of Mental Status (BIMS) score indicating intact cognitive function. Despite the resident's ability to sign herself in and out of the facility and her preference to leave for meals or appointments, these activities were not reflected in her care plan. The care plan also lacked details on where the resident would go when leaving the facility, the need for the resident to sign out, and the facility's responsibility to clean the resident's room during her absence. Interviews with facility staff, including a Registered Nurse (RN), Licensed Vocational Nurse (LVN), Social Worker, Director of Nursing (DON), and the Administrator, revealed that the resident's ability to leave the premises was known but not documented in the care plan. The staff acknowledged that the resident's activities, preferences, and goals should have been included in the care plan. The Administrator emphasized the importance of care plans in outlining the resident's permissions and expectations while residing in the facility, yet this was not executed for the resident in question.
Failure to Conduct Required PASRR Evaluation
Penalty
Summary
The facility failed to perform a Preadmission Screening and Resident Review (PASRR) for a resident with mental disorders and intellectual disabilities prior to admission. This oversight involved a resident who was originally admitted in 2018 and readmitted in 2019, with diagnoses including Alzheimer's, dementia with psychotic disturbance, mood disorder, psychotic disorder, anxiety disorder, and major depressive disorder. Despite these diagnoses, the resident's PASRR Level I screening was negative for mental illness or intellectual developmental disabilities, and a Level II evaluation was not conducted as required. Interviews with facility staff revealed a lack of awareness and understanding of the PASRR process. The MDS nurse admitted to missing the requirement for a Level II evaluation due to the resident's dementia diagnosis, which automatically greyed out the need for further screening on the forms used. The MDS coordinator also indicated that a new PASRR was not completed if one had already been done, and was unaware of the need for a new evaluation upon a change in the resident's mental health status. The Director of Nursing acknowledged the need for improvement in the system to ensure accurate data and proper care planning.
Care Plan Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment for three residents. Resident #8's care plan did not reflect her current code status of Full Code, as it was mistakenly left as Do Not Resuscitate. This oversight was acknowledged by the MDS Coordinator, who admitted that the change in code status was overlooked and not updated in the care plan. The Director of Nursing (DON) also confirmed that the code status should be care planned to guide nursing staff in emergencies, but there was confusion about who was responsible for auditing care plans. Resident #34's care plan was not updated to reflect the discontinuation of insulin use, despite the absence of any active orders for insulin. The care plan still included goals and approaches related to insulin administration, which were outdated. This discrepancy indicates a lack of communication and coordination among the care team, as the care plan was not aligned with the resident's current medical orders. Resident #48's care plan was outdated, as it still included references to wounds and a wound vac that were no longer present. Additionally, the care plan did not document that the resident was changing his own urinary catheter, a practice that had been ongoing for about a year. The staff, including the MDS Coordinator and the ADON, were unaware of this practice, and there was no order or care plan to reflect this self-care activity. The lack of documentation and communication regarding Resident #48's catheter changes highlights a significant gap in the facility's care planning process.
Food Safety and Sanitation Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, resulting in multiple deficiencies in the kitchen and nutrition rooms. Observations revealed unsanitary conditions, including gnats and a foul odor in the dish room, stained walls and floors, and a leaking ice machine with mold-like substances. Drinking glasses were found with a removable white substance, and the air filter above the refrigerator was covered in a thick, furry substance. Food items such as hot dogs were improperly stored, and freezers were not in good working order, with cracked lids and faulty seals. Kitchen staff were observed not following proper hygiene practices, such as not wearing hairnets or washing hands appropriately. A large spatula with peeling edges and eroded non-stick pans were still in use, posing a risk of contamination. The facility's cleaning schedules were not effectively implemented, as evidenced by the state of the kitchen and the lack of knowledge among staff about the cleaning procedures. The grease barrel was not properly sealed, and expired items were found in the nutrition rooms. Interviews with staff revealed a lack of training and awareness regarding food safety protocols. The dietary manager and other staff members were unaware of the extent of the issues, and there was a lack of communication with maintenance regarding necessary repairs. The facility's policies on sanitation, food storage, and handwashing were not being followed, contributing to the risk of foodborne illnesses among residents.
Pest Control Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program in the kitchen, specifically in the dish room, where multiple gnats were observed flying, and a foul odor was present. A significant structural issue was noted with a gaping hole approximately 6x6 inches in the base of a wall under the 3-compartment sink, which could allow rodents to enter. Rat droppings were also observed along the baseboard near the hole. These observations were made during an initial tour of the kitchen, and the Food Service Manager (FSM) was unaware of the hole and acknowledged that the gnats had been an ongoing problem. Interviews with the Administrator (ADM) and Maintenance Supervisor (MS) revealed a lack of awareness and documentation regarding pest control measures. The ADM was not aware of the dish room's condition and could not recall the last pest control treatment. The MS indicated that pest control was conducted as needed and monthly, but could not specify the frequency or timing of treatments for gnats. The facility's pest sighting log showed that gnats and rat droppings had been addressed on several occasions, but pest control invoices were not provided. The facility's kitchen policy emphasized the importance of preventing insect and rodent infestations, but the lack of documentation and awareness suggests a failure to adhere to these procedures.
Failure to Provide Written Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide written notification of transfer or discharge to two residents, their resident representatives, and the Office of the State Long-Term Care Ombudsman. This deficiency was identified during interviews and record reviews for two residents who were transferred to the hospital. Resident #37, a male with multiple diagnoses including Type 2 Diabetes and Covid-19, was transferred to the emergency room for low saturation and shortness of breath. The Assistant Director of Nursing (ADON) confirmed that the resident's representative was only notified verbally by phone, and no written notice was provided. Similarly, Resident #81, who had a history of a right femur fracture and other medical conditions, was transferred to the hospital after a fall. The ADON stated that the resident's representative was also notified by phone, and there was uncertainty about whether the Ombudsman was informed. The facility's policy requires documentation of transfer or discharge details in the medical record and communication with the receiving healthcare provider, but it was not followed in these cases. The Social Worker indicated that she only handled non-medical transfers and discharges and typically notified the Ombudsman via email, which had not occurred recently.
Failure to Update PASRR Screening for Resident with New Mental Health Diagnoses
Penalty
Summary
The facility failed to refer a resident for a PASRR Level II screening after the resident received new diagnoses of serious mental disorders, including Anxiety, Bipolar with Severe Psychotic Features, Adjustment Disorder, Suicidal Ideations, Depression, Personality Disorder, and Mood Disorder. The resident's PASRR evaluation did not reflect these mental health conditions, as it showed no evidence of a primary diagnosis of dementia, mental illness, or intellectual disability. Despite the resident being prescribed antianxiety and antipsychotic medications and a consult with Senior Psych Care, the necessary PASRR Level II review was not conducted. Interviews with the MDS coordinator revealed a lack of awareness regarding the need to update PASRR screenings for residents with new mental health diagnoses or significant changes in condition. The MDS coordinator believed that a new PASRR was unnecessary if one had already been completed unless the resident had a diagnosis of dementia or was evaluated at a psychiatric hospital. The DON acknowledged the need for improvement in the system to ensure PASRR accuracy and admitted that no measures had been implemented during her three-month tenure to address this issue. The DON also noted a failure in care planning and PASRR processes, indicating a need for better documentation and focus on patient needs.
Failure to Maintain Proper Catheter Care
Penalty
Summary
The facility failed to ensure that a resident's urinary catheter drainage bag did not touch the floor, which could increase the risk of urinary tract infections. The resident, a female with severe cognitive impairment and multiple medical conditions including neuromuscular dysfunction of the bladder and end-stage renal disease, required extensive assistance with daily activities. Her care plan included specific instructions for catheter care, such as keeping the drainage bag off the floor to prevent infection. Observations revealed that the resident's urinary catheter drainage bag was repeatedly found touching the floor, despite staff being aware of the proper procedures. On two separate occasions, the drainage bag was observed touching the floor, and staff had to be reminded to hang it higher. Interviews with staff members, including a CNA and an LVN, indicated that while they were aware of the importance of keeping the bag off the floor, there was a lapse in consistently following this protocol. The facility's policy and procedure for catheter care clearly stated that the drainage bag should be kept off the floor to minimize the risk of urinary tract infections. However, the failure to adhere to this policy was evident in the observations and staff interviews. The Director of Nursing acknowledged the importance of keeping the drainage bag off the floor to prevent infections and stated that staff were regularly in-serviced on catheter care, yet the deficiency persisted.
Improper Storage of Medications and Personal Items in Medication Cart
Penalty
Summary
The facility failed to ensure the safe storage of drugs and biologicals in one of the medication carts, specifically the 300-hall cart. During an observation, it was found that disinfectant wipes were stored in the same compartment as various resident liquid medications. Additionally, personal drink items, including an open water bottle and a closed energy drink, were found in the medication cart. This improper storage practice was acknowledged by RN A, who admitted that personal items should not be stored in the medication cart due to the risk of cross-contamination. RN A also recognized that disinfectant wipes, being chemicals, should be stored separately from medications. The Director of Nursing (DON) confirmed that personal items should not be in medication carts to prevent cross-contamination and that disinfectant wipes should be stored separately from medications. The facility's policy on medication storage emphasizes the need for safe, secure, and orderly storage of drugs and biologicals, with specific instructions for separating antiseptics, disinfectants, and germicides from regular medications. Despite these guidelines, the facility failed to adhere to its policy, leading to the observed deficiencies.
Facility Fails to Maintain Safe Kitchen Equipment
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe operating condition, which included a stainless-steel refrigerator, two chest type freezers, a refrigerator intake filter, an electrical box, and a sink drain. Observations revealed a dripping sink drain causing a foul odor in the dish room, an electrical box with a dangerous open hole, and an ice machine with visible contamination and leaks. The kitchen staff, including the Food Service Manager (FSM), acknowledged these issues, noting that the ice machine had been leaking for several months and that maintenance had been informed but no action was taken. The FSM also reported that the seals on the chest type freezers needed replacement and that freezer A had a cracked lid. The Maintenance Supervisor (MS) was unaware of several issues, including the dirty air filter above the refrigerator and the state of the dish room. He mentioned that there was a bid for a new ice machine and that the stainless-steel freezer was being serviced. Despite the FSM's reports, the MS believed the freezers were functioning properly and attributed ice formation to staff leaving the lids open. The facility's maintenance log and policy were requested but not provided, indicating a lack of documentation and communication regarding maintenance needs. These deficiencies could potentially place residents at risk of foodborne illness and kitchen staff at risk of injury.
Unlocked Storage and Shower Rooms Pose Safety Risks
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in three of the eight halls reviewed. Specifically, a storage room on hall 2400 was left unlocked while not in use, containing approximately 20 unopened bottles of mouthwash with alcohol. Additionally, shower rooms on halls 200 and 2200 were also left unlocked while not in use, with bottles of disinfectant left out in the open. These observations were made during a survey on August 25, 2024. Interviews with staff, including an LVN, RN, CNA, the Administrator, and the DON, revealed that the storage and shower rooms should have been locked to prevent resident access to potentially hazardous items. The staff acknowledged that mouthwash containing alcohol should not have been present in the facility, and the disinfectant should have been secured in a locked cabinet. The facility's policy on hazardous areas emphasized the importance of securing areas with potential environmental hazards to prevent resident access.
Verbal Abuse Incident Involving Staff Member
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a staff member, identified as SA, on April 29, 2024. The incident occurred when the resident confronted SA about washing the patio during a smoke break, leading to SA responding with derogatory language. Witnesses corroborated the resident's account, confirming that SA used inappropriate language. Despite the resident's immediate report to the Administrator, the facility's investigation was deemed inconclusive, and SA was not terminated but returned to work shortly after the incident. The resident involved was a female with a history of depression and diabetes, and her cognitive assessment indicated intact cognition. The incident caused the resident to feel embarrassed and anxious, particularly when she later saw SA working near her room, which heightened her fear and anxiety. Other residents and staff reported that SA frequently used abusive language towards residents, indicating a pattern of behavior that was not adequately addressed by the facility. The facility's policies on abuse prevention and resident rights emphasize the importance of a safe environment and protection from abuse. However, the Administrator's response to the incident, including the decision not to involve law enforcement and the lack of follow-up on the resident's well-being, suggests a failure to uphold these policies. The resident expressed feeling unprotected and fearful of future incidents, highlighting the facility's inadequate response to the verbal abuse incident.
Failure to Report and Address Verbal Abuse Incident
Penalty
Summary
The facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation, as evidenced by an incident involving a resident who experienced verbal abuse from a smoking attendant. The incident occurred when the smoking attendant became upset with the resident and used profane language towards her during a smoking break. This incident was witnessed and confirmed by four other residents. Despite the facility's policy requiring the reporting of such incidents to law enforcement, the facility did not contact local law enforcement, and no case number was assigned. The resident involved in the incident was a female with a history of diabetes, neuropathy, rheumatoid arthritis, heart disease, chronic skin infections, anxiety, and a left below-the-knee amputation. She had a BIMS score indicating no cognitive impairment and required little to no assistance with activities of daily living. After the incident, the resident reported feeling anxious and unprotected, especially when she saw the smoking attendant around the facility after the incident. She expressed her concerns to the social worker and the administrator, but felt that her concerns were not adequately addressed. The facility's administrator initially suspended the smoking attendant and conducted a 1:1 teachable moment with him, but the attendant was allowed to return to work in a different role without a formal suspension. The administrator's investigation concluded as inconclusive, and he did not believe the incident warranted reporting to law enforcement. The facility's policies did not clearly define the consequences for staff who verbally abuse residents, and there was a lack of follow-up to ensure the resident's well-being after the incident.
Improper Storage of Discontinued Medication
Penalty
Summary
The facility failed to securely store all drugs and biologicals in locked compartments, as required by regulations. During an observation, it was found that a nurse had left a resident's discontinued medication in a clear bin attached to the Assistant Director of Nurses' (ADON) office door. This bin was easily accessible to mobile residents and visitors, which is against the facility's policy that requires medications to be stored in a locked box or medication room. The resident involved was an elderly female with a history of dementia, cellulitis, urinary problems, and acute cystitis. Her medication, Azithromycin, was prescribed for an upper respiratory infection and was supposed to be taken over a course of several days. However, the remaining medication was improperly stored in a location accessible to unauthorized individuals, which could have led to misuse or consumption by residents with cognitive impairments. Interviews with the facility's staff, including the administrator, ADONs, and the Director of Nursing (DON), revealed that the medication was mistakenly left in the clear bin, which was intended only for empty blister packs. The staff acknowledged that the medication should have been stored in a locked narcotic box and that the clear bin should not have been used for storing medications. The facility's policy mandates that discontinued medications be removed from the medication cart and kept under lock and key, which was not followed in this instance.
Inadequate Infection Control During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CNA A during the care of a resident. CNA A did not perform hand hygiene during perineal care, which included not washing hands after touching contaminated surfaces and not using alcohol-based hand rub (ABHR) during glove changes. Additionally, CNA A did not perform under foreskin cleansing of the resident's penile area, which is a necessary step to prevent infection. The resident involved was an elderly male with severe cognitive impairment, a history of urinary tract infections (UTIs), and other medical conditions such as dementia and acute upper respiratory failure. The resident was dependent on staff for all activities of daily living, including perineal care, due to his cognitive and physical limitations. The care plan for the resident highlighted the need for thorough perineal care to prevent UTIs, which was not adhered to during the observed incident. During the observation, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) noted that CNA A did not follow the facility's guidelines for infection control, which included retracting the foreskin for cleaning and performing hand hygiene between glove changes. Despite being trained and having completed a competency checkoff for perineal care, CNA A failed to execute the required procedures, potentially exposing the resident to infection risks.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 69 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Corpus Christi
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mirador | 2.1 mi | — | 0 | 0 |
| San Rafael Nursing And Rehabiliation | 2.4 mi | — | 8 | 1 |
| Corpus Christi Nursing And Rehabilitation Center | 2.5 mi | — | 2 | 0 |
| Cimarron Place Health & Rehabilitation Center | 2.9 mi | — | 2 | 0 |
| Wooldridge Place Nursing Center | 3.1 mi | — | 10 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for The Palms Nursing & Rehabilitation.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.