Inspection visit
Inspection
33 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 33 deficiencies, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0583
Keep residents' personal and medical records private and confidential.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review the facility failed to protect the privacy of personal
information for one of 43 sampled residents (Resident 110) when Licensed Vocational Nurse (LVN) 8 did
not close Resident 110's Electronic Health Record (EHR- are electronic versions of the paper charts. An
EHR includes resident's medical history, notes, and other information about health including symptoms,
diagnoses, medications, lab results, vital signs, immunizations, and reports from diagnostic tests). The EHR
were left open, unattended and exposed for public viewing.
Residents Affected - Few
This failure had the potential for unauthorized access to resident's personal information and violated
Resident 110's right to privacy and confidentiality.
Findings:
During an observation on 11/4/21, at 9:54 a.m., in the hallway, Resident 110's EHR was left open and
unattended. LVN 8 was inside the medication room.
During an interview on 11/4/21, at 10 a.m., with LVN 8, LVN 8 verified Resident 110's EHR was left open
and unattended in the hallway. LVN 8 stated Resident 110's EHR should not be left open and unattended to
maintain Resident 110's privacy.
During an interview on 11/09/21, at 4:26 p.m., with the Director of Nursing (DON) the DON stated Resident
110's EHR should not be left open unattended to maintain Resident 110's privacy.
The facility document titled, Licensed Practical/Vocational Nurse JOB DESCRIPTION undated, indicated,
.Residents Rights .Ensures protected health information is kept confidential .
During a review of the facility Policy and Procedure (P&P) titled, Electronic Protected Health Information
Security dated 8/2020, the P&P indicated, .To ensure the security and integrity of medical records of
residents at the facility . Computers or other electronic device will be located in areas that limit access to
residents and visitors . monitors should face away from public view . Facility staff will be assigned unique
user log-in information to access the electronic record keeping system .
During a review of the facility Policy and Procedure (P&P) titled Medication Administration Subcutaneous
Insulin dated 9/18, indicated, . Residents health information needs to remain private. The pages of the MAR
notebook containing resident health information must remain closed or covered when not in direct use .
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 48
Event ID:
055047
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055047
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center
1010 Ventura Avenue
Chowchilla, CA 93610
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0657
Level of Harm - Minimal harm
or potential for actual harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
Based on observation, interview, and record review, the facility failed to implement and timely revise a
person-centered comprehensive care plan for one of three sampled Residents (Resident 18) when:
Residents Affected - Few
1. Resident 18's care plan for use of indwelling urinary catheter (IUC-a catheter drains urine from your
bladder into a bag outside the body) was not reviewed or revised by the Interdisciplinary Team (IDT-group
composed of a physician, a nurse and appointed facility staff who meet and discuss the care of the
residents).
This failure had the potential for Resident 18's to develop urinary tract infections (UTI-infection of the
urinary tract) and not following his specific care needs for the IUC.
Findings:
During an interview on 11/03/21, at 2:03 p.m., with Licensed Vocational Nurse (LVN) 9, LVN 9 stated
Resident 18 had an IUC since admission and is diagnosed with obstructive uropathy (is a structural or
functional hindrance of normal urine flow, sometimes leading to renal dysfunction). LVN 9 stated Resident
18's care plan was not personalized or revised since admission.
During a concurrent interview and record review, on 11/03/21, at 2:18 p.m., with the Director of Nursing
(DON), Resident 18's Electronic Health Record (EHR- are electronic versions of the paper charts. An EHR
includes resident's medical history, notes, and other information about health including symptoms,
diagnoses, medications, lab results, vital signs, immunizations, and reports from diagnostic tests) was
reviewed. The EHR indicated Resident 18's IUC was permanent. The DON stated Resident 18's EHR
indicated he was diagnosed with Benign Prostatic Hyperplasia (BPH-condition in which an overgrowth of
prostate tissue pushes against the urethra and the bladder) and dysfunction (not working normally) of
bladder. The DON stated Resident 18 had IUC since 2020. The DON stated the care plan was not updated
since his admission. The DON stated the catheter care plan should have been implemented and revised
since 12/14/2020 and quarterly thereafter.
During a concurrent interview and record review, on 11/05/21, at 9:54 a.m., with LVN 5, Resident 18's care
plan was reviewed. LVN 5 stated, Resident 18's care plan was initiated on 12/14/2020 and should have
been revised quarterly. LVN 5 stated Resident 18's was at risk for developing UTI if the IUC stayed in long
term.
During a review of the Center for Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI)
Version 3.0 Manual, dated 10/2019 indicated, .The plan of care must be reviewed and revised periodically,
and the services provided must be consistent with each resident's written plan of care .
During a review of facility document titled Care Planning dated 6/2020, indicated, .A comprehensive
person-centered Care Plan will be developed for each resident. The Care Plan will include measurable
objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs .in the
event that the Comprehensive Care Plan identified a change in the resident's goals or functioning that was
not identified in the Baseline Care Plan, these changes will be incorporated into an updated summary and
provided the resident and /or resident's representative .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055047
If continuation sheet
Page 2 of 48
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055047
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center
1010 Ventura Avenue
Chowchilla, CA 93610
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0658
Ensure services provided by the nursing facility meet professional standards of quality.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview and record review, the facility failed to provide services which meet
professional standards of quality for three of 43 sampled residents (Resident 40, Resident 110, and
Resident 56 .) when:
Residents Affected - Some
1. Resident 40 was administered oxygen without following physician's order.
This failure resulted in Resident 40 to receive a high dose of oxygen and had the potential to experience
oxygen toxicity (a lung damage that happens from breathing too much (supplemental) oxygen. It can cause
coughing and trouble breathing. In severe cases it can even cause death.) Which can lead to difficulty in
breathing and death.
2. License Vocational Nurse administered insulin by way of an insulin pen to Resident 110 and Resident 56
without disinfecting the insulin pen rubber seal, did not prime (a method to remove air bubbles from the
needle to ensure it is working, and full dose administration) the pen, and did not hold the pen at the
injection site for 5-10 seconds prior to pulling the needle out.
This failure placed Resident 110 and Resident 56 at risk for an inaccurate insulin dosage and impaired
insulin absorption (movement of a medication from the site of administration to bloodstream) and cross
contamination.
Findings:
1. During an observation on 11/2/21, at 2:18 p.m., in Resident 40's room, Resident 40 was laying in bed
with the oxygen concentrator (a medical device that provides oxygen) connected to her nose via nasal
cannula (is a small, flexible tube that attaches to an oxygen source and intended to deliver a steady stream
of oxygen to your nose). The oxygen concentrator flow rate was set to administer oxygen at 5 liters per
minute (unit of measurement).
During a concurrent observation and interview, on 11/2/21, at 2:31p.m., with License Vocational Nurse
(LVN) 5, LVN 5 verified the oxygen concentrator flow rate was set to deliver at 5 liters per minute of oxygen
to Resident 40. LVN 5 stated she will check Resident 40's physician's order for Oxygen.
During an interview on 11/2/21 at 2:41 p.m., with LVN 5, LVN 5 stated Resident 40's physician's order for
Oxygen was to administer oxygen at 2 liters per minute. LVN 5 stated she did not follow physician's order.
LVN 5 stated Resident 40 had a diagnosis of Chronic Obstructive Pulmonary Disease (it's a long lasting
lung disease which limits the flow of oxygen in and out the lungs) and if given too much oxygen can cause
difficulty breathing for Resident 40.
During an interview on 11/9/21, at 3:18 p.m., with LVN 5, LVN 5 stated oxygen was considered a
medication and was prescribed by a physician and the physician's orders should be followed.
During an interview on 11/9/21, at 4:26 p.m., with the Director of Nursing (DON), the DON stated oxygen
was considered a medication and physician's order should be followed to prevent oxygen toxicity for
Resident 40.
During a review of Resident 40's admission Record dated 2/17/19, the admission Record indicated
Resident 40 was admitted in the facility with a diagnosis of COPD.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055047
If continuation sheet
Page 3 of 48
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055047
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center
1010 Ventura Avenue
Chowchilla, CA 93610
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0658
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
During a review of Resident 40's Order Summary Report dated 2/17/19, the Order Summary Report
indicated, .Oxygen @[at] 2 l/min [liters per minute] .)
During a review of the facility document titled, Licensed Practical/Vocational Nurse JOB DESCRIPTION
undated, indicated, . Principal Responsibilities . Ability to carry out physician orders . Special Nursing Care
Responsibilities .Demonstrate knowledge and ability to implement . properly administers O2 [oxygen] .
During a review of the professional reference titled, Harms of over oxygenation in patients with
exacerbation of chronic obstructive pulmonary disease retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5461124/ dated 6/5/2017, indicated, .Too much oxygen can
be dangerous for patients with Chronic Obstructive Pulmonary Disease (COPD) with (or at risk of)
hypercapnia (the presence of excessive amount of carbon monoxide [a colorless odorless toxic gas] in the
blood).
During a review of the professional reference tiled, Bench to bedside review: Oxygen as a drug retrieved
from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2688103/ dated 2/24/2009, indicated, .Oxygen is one
of the most widely used therapeutic agents. It is a drug in the true sense of the word, with specific
biochemical and physiologic actions, a distinct range of effective doses, and a well-defined adverse effects
at high doses .
During a review of the facility policy and procedure (P&P) titled, Oxygen Administration dated 6/2020, the
P&P indicated, .A physician's order is required to initiate oxygen therapy . The order shall include: Oxygen
flow rate, Method of administration (e.g. nasal cannula) . The P&P titled, Medication Administration dated
9/2019, indicated, .Medications are administered in accordance with the written orders of the prescriber .
2. During a medication administration observation, on 11/04/21, at 10:08 a.m., LVN 8 administered
NovoLOG insulin (rapid-acting insulin used to control high blood sugar in adults) 6 units (unit of
measurement) by way of an insulin pen to Resident 110. LVN 8 did not prime the NovoLOG insulin pen
prior to the insulin administration to Resident 110. LVN 8 injected the insulin to Resident 101's arm and
quickly removed the needle from Resident 110's arm without allowing the pen needle to remain under the
skin for 5 seconds.
During a review of Resident 110's, admission Record (a document containing resident profile information)
dated 11/3/21, the admission Record indicated, Resident 110 was admitted to the facility with diagnosis of
Type 2 Diabetes Mellitus (a long-term disorder that is characterized by high blood sugar).
During a review of Resident 110's, Order Summary Report dated 8/21/19, the Orders Summary Report
indicated, .Insulin NovoLOG Solution Inject as per sliding scale: 0-200 = 0; 201-250 = 2; 251-300 = 4; 400 =
6; 401- 450 = 8, subcutaneously (under the skin) one time a day related to Hyperglycemia (high blood
sugar in the blood) .
During an interview on 11/4/21, at 10:11 a.m., with LVN 8, LVN 8 stated he did not prime the insulin pen,
and did not wait 5 seconds to remove the needle from Resident 110 after injection. LVN 8 stated he had
been a license nurse for 25 years and never heard of priming the insulin pen.
During a medication administration observation, on 11/4/21, at 12:33 p.m., LVN 3 administered insulin
Lispro (fast-acting insulin used to control high blood sugar in adults) 5 units (unit of
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055047
If continuation sheet
Page 4 of 48
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055047
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center
1010 Ventura Avenue
Chowchilla, CA 93610
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0658
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
measurement) via an insulin pen to Resident 56. LVN 3 did not disinfect the insulin pen rubber seal prior to
attaching the needle and did not prime the insulin Lispro pen prior to the insulin administration to Resident
56. LVN 3 injected the insulin to Resident 56's arm and quickly removed the needle from Resident 56's arm
without allowing the pen needle to remain under the skin for 5 seconds.
During an interview on 11/4/21, at 12:50 p.m., with LVN 3, LVN 3 stated she did not disinfect the insulin pen
rubber seal before attaching the needle, did not prime the insulin pen, and did not wait 5 seconds to
remove the needle from Resident 56 after injection. LVN 3 stated she was not aware she needed to prime
the insulin pen and wait 5 seconds prior to removing the needle from Resident 56.
During a review of Resident 56's admission Record dated 1/17/2020, the admission Record indicated,
Resident 56 was admitted to the facility with diagnosis of Type 2 Diabetes Mellitus.
During a review of Resident 56, Order Summary Report dated 10/12/21, the Order Summary Report
indicated, .Insulin Lispro Solution Pen-Injector 100 UNIT/ML [milliliter] inject 5 unit subcutaneously with
meals related Type 2 Diabetes Mellitus .
During an interview with the Director of Nursing (DON), on 11/4/21, at 3:02 p.m., she stated the license
nurse should have primed the insulin pen prior to administration. The DON stated the nurse should have
kept the pen needle under the skin for 5 seconds after injecting the insulin to ensure the insulin was
absorbed. The DON stated the insulin pen rubber seal should be disinfected prior to attaching the needle to
prevent cross contamination.
During a review of the facility document titled, Licensed Practical/Vocational Nurse JOB DESCRIPTION
undated, the Licensed Practical/Vocational Nurse JOB DESCRIPTION indicated, .Principal Responsibilities
. Responsible for ensuring the delivery of efficient and effective nursing care while achieving positive clinical
outcomes and resident/family satisfaction in accordance with accepted standards of practice, stated and
federal regulations and licensing requirements . Ability to administer medications and treatment timely and
according to facility policy .
During a review of the facility Policy and Procedure (P&P) titled Medication Administration Subcutaneous
Insulin dated 5/2016, the P&P indicated, . Always perform the safety test before each injection. Performing
the safety test ensures that you get an accurate dose by: ensuring that pen and the needle work properly.
Removing air bubbles . Hold the pen with the needle pointing upwards. Tap the insulin reservoir so that air
bubbles rise up towards the needle. Press the injection button all the way in. Check if insulin comes out of
the needle tip. You may have to perform the safety test several times before insulin seen. If no insulin comes
out, check for air bubbles and repeat the safety test two more times to remove them. If no insulin comes
out, the needle may be blocked .Deliver the dose by pressing the injection button in all the way . Keep the
injection button pressed all the way. Slowly count to 10 before you withdraw the needle from the skin. This
ensures that the full dose will be delivered .
During a review of the professional reference titled, Insulin Pen Injections dated 8/2018, retrieved at
https://my.clevelandclinic.org/health/treatments/17923-insulin-pen-injections, indicated, .How do I use an
insulin pen? Wipe the rubber stopper with an alcohol wipe . Prime the insulin pen. Priming means removing
air bubbles from the needle, and ensures that the needle is open and working. The pen must be primed
before each injection . To prime the insulin pen, turn the dosage knob to the 2 units indicator. With the pen
pointing upward, push the knob all the way. At least one drop of insulin should appear. You may need to
repeat this step until a drop appears. Select the dose of insulin
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055047
If continuation sheet
Page 5 of 48
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055047
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center
1010 Ventura Avenue
Chowchilla, CA 93610
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0658
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
that has been prescribed for you by turning the dosage knob . Injecting insulin with an insulin pen: .Slowly
push the knob of the pen all the way in to deliver your full dose. Remember to hold the pen at the site for
6-10 seconds, and then pull the needle out .
During a review of the professional reference titled, Risk associated with the use of Insulin pens and Vials
dated 2017, (retrieved at
https://www.ismp.org/sites/default/files/attachments/2017-11/ISMP138-Insulin%20Guideline-051517-2-WEB.pdf),
indicated, . nurses have reported seeing a wet spot on the skin post injection due to insulin leaking from the
injection site because the needle was not left in place for 5-10 seconds after injection .
During a review of the professional reference titled, Severe hyperglycemia in patients incorrectly using
insulin pens at home dated 10/2017, (retrieved at
https://www.ismp.org/alerts/severe-hyperglycemia-patients-incorrectly-using-insulin-pens-home), indicated,
. Prior to injection, the pen should be primed using 2 to 3 units of insulin to make certain that the needle is
correctly attached and to remove any air bubbles or pockets in the insulin cartridge. This is known as an air
shot and the patient should see about 2 drops of insulin come out of the needle .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055047
If continuation sheet
Page 6 of 48
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055047
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center
1010 Ventura Avenue
Chowchilla, CA 93610
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure bowel and bladder training program
was developed for one of three sampled residents (Resident 18) when Resident 18' s bowel and bladder
(B&B) training program (a training program to overcome bladder problems) was not developed for the
indwelling urinary catheter (IUC-a catheter drains urine from your bladder into a bag outside your body).
This failure had the potential for Resident 18's to develop urinary tract infections (UTI-infection of the
urinary tract) and loss of opportunity to regain bowel and bladder function.
Findings:
During a concurrent interview and record review, on 11/3/21, at 2:03 p.m., with LVN 9, Resident 18's
electronic health record (EHR- are electronic versions of the paper charts. An EHR includes resident's
medical history, notes, and other information about health including symptoms, diagnoses, medications, lab
results, vital signs, immunizations, and reports from diagnostic tests) was reviewed. The EHR indicated,
Resident 18 had IUC. LVN 9 stated Resident 18's care plan did not mention a B&B training program. LVN 9
stated Resident 18 should have been on a bowel and bladder (B&B) training program to restore his bladder
function. LVN 9 stated Resident could have UTIs and loss of bladder function if a B&B training program was
not implemented.
During a concurrent interview and record review, on 11/03/21, at 2:18 p.m., with the DON, Resident 18's
Interdisciplinary Team (IDT) Notes were reviewed. The IDT (group composed of a physician, a nurse and
appointed facility staff who meet and discuss the care of the residents) notes did not indicated Resident
18's B&B training program was discussed. The DON stated Resident 18's EHR indicated he was diagnosed
with Benign prostatic hyperplasia (BPH-condition in which an overgrowth of prostate tissue pushes against
the urethra and the bladder) and dysfunction (not working normally) of bladder. The DON stated Resident
18 had a IUC since 2020. The DON was unable to find documentation that a B & B training program was
discussed with Interdisciplinary Team (IDT-group composed of a physician, a nurse and appointed facility
staff who meet and discuss the care of the residents) and was implemented.
During a concurrent interview and record review, on 11/05/21, at 9:36 a.m., with LVN 5, Resident 18's EHR
was reviewed. LVN 5 stated there was no documentation that B&B training trial was attempted. LVN 5
stated the facility did not have a policy on B & B training. LVN 5 stated Resident 18 would be at risk to
develop urinary tract infections since the IUC was permanent. LVN 5 stated no attempt was made to regain
Resident 18's bladder function.
During a concurrent interview and record review, on 11/05/21, at 3:36 p.m., with the DON, Resident 18's
Nursing Bowel and Bladder Assessment was reviewed. Resident 18's Nursing Bowel and Bladder
assessment dated [DATE], indicated, .1. Type of Toileting Program .b. Prompted Voiding .d. Check and
change . The DON stated Resident was not on a B&B training program and the assessment was
inaccurate. The DON stated the accuracy of the documentation for Resident 18's Bowel and Bladder
Assessment and Foley Catheter Use Assessment was the Minimum Data Set [MDS- a resident
assessment tool used to identify cognitive (mental processes)] Coordinator's (MDSC) responsibility. The
DON stated the facility did not have a policy on Bowel and Bladder Training program.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055047
If continuation sheet
Page 7 of 48
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055047
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center
1010 Ventura Avenue
Chowchilla, CA 93610
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
During a concurrent interview and record review, on 11/05/21, at 4:05 p.m., with the MDSC, the Nursing
Bowel and Bladder Assessment was reviewed, dated 9/15/21, indicated, .1. Type of Toileting Program .b.
Prompted Voiding .d. Check and change . The MDSC stated Resident 18's bowel and bladder assessment
was documented incorrectly on the MDS because Resident 18 had an IUC and was not on a B&B training
program. The MDSC stated Resident 18's care could be affected if the assessment for bowel and bladder
function was not done accurately.
During a review of the Center for Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI)
Version 3.0 Manual, dated 10/2019 indicated, .Each resident who is incontinent or at risk of developing
incontinence should be identified, assessed, and provided with individualized treatment (medications,
non-medicinal treatments and/or devices) and services to achieve or maintain as normal elimination
function as possible .Residents may need to be referred to practitioners who specialize in diagnosing and
treating conditions that affect bladder function .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055047
If continuation sheet
Page 8 of 48
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055047
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center
1010 Ventura Avenue
Chowchilla, CA 93610
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0693
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and
provide appropriate care for a resident with a feeding tube.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to provide enteral G-tube (Gastrostomy tube that
is placed directly into the stomach for administration of food, fluids, and medications) feeding per physician
order, for one of three sampled residents (Resident 42) when; Resident 42 did not have training to
self-administer enteral feeding and administered an incorrect formula by adding water to his enteral
feeding.
This failure resulted in Resident 42 receiving more water than prescribed and had the potential to cause
adverse complications.
Findings:
During a concurrent observation and interview on 11/2/21, at 12:12 p.m., with Resident 42, in Resident 42's
room, Resident 42 stated, he had been a carpenter and was able to pick up on this quickly. Resident 42
stated, he had watched nurses do the enteral feeding a thousand times and was able to do it by himself.
Resident stated he would demonstrate how he self-administered the enteral feeding via his G-tube.
Resident 42 proceeded by opening the gravity bag (gravity feeding is a way to deliver feeding formula
through the feeding tube. With this feeding method, formula flows out of a bag and into the tube by gravity)
lid and poured approximately 300 ml (ml- milliliter-a unit of measurement) of water from a water pitcher then
poured two bottles containing 237 ml of [brand name (enteral feeding)] into the bag. Resident 42 stated, he
usually pours 400 to 500 ml of water and stated there was approximately. 750 ml total in the bag then
began to administer the formula via the G-tube.
During a review of Resident 42's Minimum Data Set (MDS- a resident assessment tool used to identify
cognitive (mental processes) and physical functional level assessment dated [DATE], the MDS indicated
Resident 42's Brief Interview for Mental Status (BIMS - screening tool used to assess resident cognitive
level) score was 15 out of 15 (0-7 indicated severe cognitive impairment - [memory loss, poor decision
making-skills] 8-12 moderate cognitive impairment, (13-15) cognitively intact).
During a concurrent interview and record review on 11/3/21, at 2:56 p.m., with Licensed Vocational Nurse
(LVN) 1, Resident 42's Order Summary Report (OSR) dated 11/2021 indicated, .Enteral Feed Order every
6 hours [Brand Name (enteral feeding)] 1.5 2 cartons at 0000 1 carton 0600, 2 carton 1200, 1 carton 1800
Q [every] 6 hours via gravity bag to deliver 2133 kcals [kilocalories], 1422ml [milliliters], 30g [grams, a unit
of measurement] Fiber, 91g protein, 1090ml H2O (water) . Resident incapable of administering own
medication . LVN 1 stated, there was no MD order indicating that Resident 42 was capable of administering
his own enteral feeding and there should have been an physician's order in place. LVN 1 reviewed the
clinical record and stated, there was no assessment or education given to Resident 42 to ensure the safe
administration of the enteral feeding. LVN 1 stated, she did not know if Resident 42 administered his enteral
feeding per physician order because she did not observe himself administer the enteral feeding. LVN 1
stated, adding 300 - 400 ml water to the bag was not part of the enteral feed physician's order.
During an interview on 11/3/21, at 3:38 p.m., with the Director of Nursing (DON), the DON stated, there
was no physician order, education, or an Interdisciplinary Team (IDT- involves team members from different
disciplines working collaboratively, with a common purpose, to set goals, make decisions and share
resources and responsibilities for the best interest of the resident) meeting to ensure
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055047
If continuation sheet
Page 9 of 48
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055047
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center
1010 Ventura Avenue
Chowchilla, CA 93610
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0693
Level of Harm - Minimal harm
or potential for actual harm
safety and capability of self-administration of enteral feeding for Resident 42. The DON stated, Resident 42
should have been educated and it was the IDT's responsibility to educate and re-educate for
self-administration of enteral feeding. The DON stated the purpose of educating and re-educating Resident
42 was to ensure safe administration of enteral feeding. The DON stated, the order did not indicate to add
water to the bag during the enteral feeding.
Residents Affected - Few
During an interview on 11/4/21, at 10:59 a.m., with the Administrator (ADM), the ADM stated, there was no
in-service education or re-education for Resident 42 to self-administer enteral nutrition. The ADM stated,
the facility did not have a policy on Resident self-administration for enteral feeding.
During a concurrent interview and record review on 11/5/21, at 11:48 p.m., with LVN 5, the facility policy
and procedure titled, Self Administration of Drugs dated 11/2010 was reviewed. The policy indicated, .The
staff or practitioner will periodically (for example, during quarterly MDS reviews) reevaluate a resident's
ability to continue to self-administer medications . LVN 5 stated, enteral nutrition was not considered a
medication but the policy would apply to enteral feeding because an evaluation and education should be
done for safety.
During a telephone interview on 11/5/21, at 2:01 p.m., with the Registered Dietitian (RD), the RD stated,
she was aware that Resident 42 was self-administering enteral nutrition. The RD stated, she had not
observed Resident 42 self-administer enteral nutrition. The RD stated, there should be a physician order
indicating, Resident 42 was capable of self-administering enteral nutrition and education to avoid
complications.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055047
If continuation sheet
Page 10 of 48
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055047
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center
1010 Ventura Avenue
Chowchilla, CA 93610
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0700
Level of Harm - Immediate
jeopardy to resident health or
safety
Residents Affected - Some
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a
resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed
consent; and (4) Correctly install and maintain the bed rail.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure five of five Residents (Residents 6, 8,
11, 16, and 55) were assessed for the risk of entrapment (resident caught, trapped, or entangled in the
space in or about the bed and side rail) from bed (side) rails (adjustable metal or rigid plastic bars in various
sizes that attach to the bed, and can be placed in a guard (raised) or lowered) prior to installation and had
no consent (form signed by resident or family explaining the risks of side rail use), physician order,
indication for use, and care plans prior to the use of side rails when:
1. Resident 6 had two bed rails raised up and had sustained an injury of unknown origin on 10/29/2021
prompting the facility to pad the bed rails. Prior to the use of the two bed rails, staff did not conduct an
entrapment risk assessment; no consent, physician order and care plan were done prior to the use of the
two bed rails for Resident 6.
2. Resident 16 had two bed rails on both sides of the bed in the guard position (A position that is intended
to prevent an individual from inadvertently rolling out of bed). Resident 16 did not have a physician's order,
consent, and plan of care prior to the use of the bed rails.
3. Resident 11 had two bed rails on both sides of the bed in the guard position and did not have a consent
prior to use of bed rails.
4. Resident 8 had two bed rails on both sides of the bed in the guard position and did not have a physician's
order, consent, entrapment risk assessment, and plan of care prior to use of the bed rails.
5. Resident 55 had two bed assist bed rails in the guard position and no entrapment risk assessment,
consent, physician order and care plan were done prior to use.
These failures had the potential to cause entrapment, serious harm, injury, or death to Residents 6, 8, 11,
16, and 55.
Because of the serious potential harm such as injury and entrapment to Residents 6, 8, 11, 16, and 55 and
the serious potential harm to all residents with bed rails used without an entrapment risk assessment, no
consent, no physician order, no indication for use, and no care plans prior to use, an Immediate Jeopardy
(IJ, a situation in which non-compliance with one or more regulatory requirements has caused or is likely to
cause serious injury, harm, impairment, or death to a resident) situation was called., on 11/4/2021 at 6:07
p.m., under Code of Federal Regulations (CFR) 483.25 (F700) with the Administrator (ADM) and Director of
Nursing (DON). The facility was provided the IJ template which indicated the need to submit an acceptable
written Plan of Removal that addressed the need for immediate action for the IJ situation. The facility
submitted a Plan of Removal (POR) on 11/8/21, at 11:02 p.m., to address the IJ situation. The IJ POR
included: 1) immediately conduct entrapment risk assessments for affected Residents, obtain consents for
all affected residents and obtain physician's order and develop and implement a care plan for each affected
resident. 2) Develop immediate safety processes and monitoring steps to ensure the residents do not get
entrapped and sustain injuries. 3) Implement processes regarding the difference between bedrolls and/or
mobility aids, consents, physician orders, entrapment risk assessment, care planning, equipment
monitoring & maintenance that
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055047
If continuation sheet
Page 11 of 48
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055047
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center
1010 Ventura Avenue
Chowchilla, CA 93610
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0700
Level of Harm - Immediate
jeopardy to resident health or
safety
Residents Affected - Some
would ensure all residents' safety. 4) Implement Training and Education and measure of competencies to all
staff regarding Physical Restraints [Physical Restraint is defined as any manual method or physical or
mechanical device, material, or equipment attached or adjacent to the resident's body that the individual
cannot remove easily which restricts freedom of movement or normal access to one's body]/Bedrails to
ensure residents' safety at all times. The IJ Plan of Removal was accepted on 11/8/21 at 12:28 p.m. While
onsite, the surveyors validated the POR implementation action items through observations, interviews,
record reviews and confirmed that all POR action interventions to address the IJ situation were fully
implemented. The IJ was removed on 11/8/21 at 5:50 p.m., with the ADM.
Findings:
1. During an observation on 11/2/21, at 2:55 p.m., in Resident 6's room, Resident 6 was asleep in bed with
two bed rails up and a soft, hallow piece of foam covered the top of the half bed rails.
During an interview on 11/3/21, at 3:09 p.m., with the DON, the DON stated Resident 6 had an injury of
unknown origin on 10/29/21. The DON stated Certified Nursing Assistants (CNAs) were doing last rounds
on 10/29/21 and saw Resident 6's right hand was reddened, swollen and warm to touch. The DON stated
Licensed Vocational Nurse (LVN) 1 called her to look at Resident 6's right hand. The DON stated Resident
6 said don't touch when the DON looked at her hand. The DON stated an x-ray (digital image of a part of
the body) was done at the facility. The DON stated Resident 6's physician wanted the staff to place a soft
splint (soft, padded material that is used to secure an injury by holding it in place ) on her right hand. The
DON stated Resident 6 would not let staff put a splint on her hand. The DON stated Resident 6 was sent to
the hospital on [DATE] to get a splint on the right hand, and the hospital repeated the x-ray. The DON stated
the x-ray at the hospital showed no fracture of the right hand. The DON stated the x-ray indicated
degenerative joints (decrease in function of joints) of Resident 6's right hand. The DON stated the hospital
placed a soft splint on Resident 6's hand. The DON stated staff or residents did not witness the injury. The
DON stated Resident 6's injury could have occurred as a result of her hand hitting the bed rail.
During an interview on 11/3/21, at 3:38 p.m., with LVN 1, LVN 1 stated CNA 3 asked her to look at Resident
6's right hand on 10/29/21 at 2:24 p.m. LVN 1 stated Resident 6's knuckles on her right hand were red,
swollen, and warm to touch. LVN 1 stated staff had not reported any past falls for Resident 6. LVN stated
the physician ordered x-rays of Resident 6's right hand. LVN stated the x-ray was done at the facility. LVN
stated the x-ray results showed Resident 6 had a fracture. The physician ordered to put a splint on Resident
6's right hand. LVN 1 stated the staff was not able to get a splint on Resident 6's hand and Resident 6 was
sent out to the hospital to get her right hand splinted. LVN 1 stated the second x-ray that was done at the
hospital on [DATE] did not indicate a fracture. LVN 1 stated that after the injury Resident 6's side rails were
padded to keep her from hurting her hand. LVN 1 stated Resident 6's injury could have been caused by her
hitting the bed rail.
During a concurrent interview and record review on 11/3/21, at 3:38 p.m. with LVN 1, Resident 6's
Radiology Interpretation, dated 10/29/21, was reviewed. The X-ray indicated, .Impression: Impaction
fractures age unknown, distal right second and third metacarpals (miniature long bone near the second and
third finger of the right hand) . LVN 1 stated the first x-ray was done at the facility on 10/29/21. LVN 1 stated
the second x-ray was done at the hospital on [DATE]. The second X-ray indicated, .Findings: . There is no
acute fracture or dislocation. Advanced degenerative changes involving interphalangeal and first carpal
metacarpal joints (first joint of the finger and is located between the first two bones of the finger). Soft
tissues (supports internal bones) are unremarkable .
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055047
If continuation sheet
Page 12 of 48
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055047
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center
1010 Ventura Avenue
Chowchilla, CA 93610
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0700
Level of Harm - Immediate
jeopardy to resident health or
safety
Residents Affected - Some
During a concurrent observation and interview, on 11/4/21, at 9:40 a.m., with CNA 1 in Resident's 6 room,
Resident 6's bed had two bed rails up. CNA 1 stated the bed rails were padded because Resident 6 had
hurt her hand. CNA 1 stated they used two CNAs to get Resident 6 up because she sometimes hits at
them. CNA 1 stated Resident 6's injury could have been a result of her hand hitting the bed rail.
During a concurrent interview and record review, on 11/4/21, at 1:00 p.m., with LVN 3, Resident 6's
electronic health record (EHR), dated between 10/1/21 and 10/30/21 was reviewed. LVN 3 stated she could
not find the physician's order, no entrapment risk assessment, no consent, or care plan for the padded
bedrails before the injury on 10/29/21. Resident 6's care plan indicated padded bed rails were initiated on
10/30/21. LVN 3 stated there should be a physician's order, an entrapment risk assessment, a consent form
signed by Resident 6's responsible party and a care plan done before the bed rails were used for Resident
6.
During an interview, on 11/4/21, at 2:37 p.m., with the CNA 2, the CNA 2 stated she had worked at the
facility since September 2021 and was familiar with Resident 6. CNA 2 stated Resident 6 would swat at the
staff and was confused at times. CNA 2 stated Resident 6 had bed rails up since she started working at the
facility in 2021.
During a concurrent interview and record review, on 11/4/21, at 2:43 p.m., with LVN 4, Resident 6's EHR,
dated 10/1/21 to 11/4/21 was reviewed. LVN 4 stated there were no consent form, and physician orders for
the bed rails for Resident 6. LVN 4 stated she did not recall how long Resident 6 had been using bed rails.
During a concurrent observation and interview, on 11/4/21, at 3:15 p.m. with Director of Maintenance
(DOM), in Resident 6's room, Resident 6's had two bed rails up. DOM stated the bed rails came with
Resident 6's bed. DOM stated he put the padding on the bed rails. DOM was unable to provide a copy of
the Resident 6's bed manufacturer's guidelines. DOM demonstrated how Resident 6 was supposed to lower
the bed rails by pulling on a knob below the side rail. DOM stated Resident 6 could not remove the bed rail
because she was unable to reach down to where the knobs were located on the bed.
During a concurrent observation and interview on 11/4/21, at 3:34 p.m., with the Director of Rehabilitation
(DOR) in Resident 6's room, Resident 6's bed rails were observed up. DOR stated there should be an
entrapment risk assessment, and a consent form prior to use. DOR stated the bed rails were considered a
restraint since Resident 6 was unable to remove it. DOR stated the importance of doing an entrapment risk
assessment was to prevent entrapment injury.
During an interview on 11/4/21, at 5:37 p.m. with the DOM, the DOM stated he was responsible for
installing bed rails on Resident 6's bed. The DOM stated he did not perform necessary measurements to
ensure bed and bed rail compatibility for Resident 6 and other residents with bed rails. The DOM stated that
he was unaware of the requirements for the measurements of the bed rails.
During a review of the facility's policy and procedure (P&P) titled, Bed Rails, dated June 2020, the P&P
indicated, .Maintenance/Designee will assess the bed dimensions no less than quarterly by utilizing
Maintenance Inspection Checklist-Resident Rooms. Maintenance will also check bed rails regularly to
ensure they are installed correctly, as rails may shift or loose over time .
During a concurrent observation and interview on 11/4/21, at 5:53 p.m., with CNA 2, CNA 3, and the DON
in Resident 6's room, CNA 3 stated the bed rails on Resident 6's bed was used as a mobility
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055047
If continuation sheet
Page 13 of 48
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055047
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center
1010 Ventura Avenue
Chowchilla, CA 93610
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0700
Level of Harm - Immediate
jeopardy to resident health or
safety
Residents Affected - Some
device. CNA 2 asked Resident 6 to grab the bed rails, Resident 6 did not follow commands and did not grab
the bed rails. CNA 2 stated Resident 6 would not be able to remove the bed rails.
During a concurrent interview and record review, on 11/5/21, at 9:15 a.m. with ADM, Facility Reported
Event (Facility Reported Event), dated 10/30/21 was reviewed. The Facility Reported Event indicated, on
10/29/2021 .CNA notified the LVN that resident had redness, warm and swelling to her right hand .notified
the physician and received and order for x-ray to right hand .All LVNs and CNAs were interviewed .Through
an investigation of residents behaviors and interviews of staff .the Interdisciplinary Team (IDT-staff
members of different expertise that work together toward a common goal for the resident) determined that
redness and swelling of the hand was likely caused by accident by the resident . ADM stated that the staff
determined that Resident 6 probably hit her hand on the bed rail causing her injury. ADM stated nobody
actually witnessed the injury.
During an interview on 11/5/21, at 2:50 p.m. with Resident 6's responsible party (RP), the RP was notified
by the facility regarding Resident 6's injury of unknown origin on 10/29/21. RP stated Resident 6 had
cracked bones in her right hand and thought Resident 6 was probably trying to grab something on her
bedside table and hit her hand against the bed rail.
During a review of Resident 6's Minimum Data Set (MDS- a resident assessment tool used to identify
cognitive (mental processes) and physical functional level assessment were reviewed. MDS dated [DATE],
indicated, .Resident 6's Brief Interview for Mental Status (BIMS - screening tool used to assess resident
cognitive level) score was 3 out of 15 (0-7 indicated severe cognitive impairment - [memory loss, poor
decision making-skills], 8-12 moderate cognitive impairment, and (13-15) cognitively intact) . MDS Section
G (Function Status) indicated . B. Transfer how resident moves between surfaces including to or from: bed,
chair, wheelchair, standing position . code 3 (two-person physical assist) . C. Walk in room how resident
walks between locations in her room Code 8 (activity did not occur) . D. Walk in corridor how resident walks
in corridor on unit . code 8 .
5. During an observation on 11/4/21, at 2:39 p.m., in Resident 55's room, Resident 55 was laying on his
back in bed, with two assist bed rails attached to the midsection of the bed and was in the guard down
position. Resident 55's bed was observed in the low position with two floor mats on both sides of the bed.
During a concurrent observation and interview on 11/4/21, at 2:42 p.m., with CNA 2, in Resident 55's room,
Resident 55 was laying in bed with both bed rails in the lowered position. CNA 2 stated, Resident 55 was
not alert and required total assist for mobility. CNA 2 stated, Resident 55's bed rails were in place to prevent
him from falling out of bed.
During a review of Resident 55's Minimum Data Set and physical functional level assessment dated [DATE],
the MDS indicated Resident 55's Brief Interview for Mental Status score was 0 out of 15, Section G
indicated . B. Transfer how resident moves between surfaces including to or from: bed, chair, wheelchair,
standing position . code 3 . C. Walk in room how resident walks between locations in her room Code 8 . D.
Walk in corridor how resident walks in corridor on unit . code 8 .
During a concurrent interview and record review on 11/4/21, at 3:01 p.m., with Minimum Data Set
Coordinator (MDSC), MDSC reviewed Resident 55's clinical record. MDSC stated, he did not know when
the bed rails were installed on Resident 55's bed. MDSC reviewed the clinical record and stated there was
no physician order, no informed consent for bed rail use, no bed rail care plan, and no entrapment risk
assessment. MDSC reviewed Section P of the MDS, dated [DATE] titled, Restraint and Alarms,
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055047
If continuation sheet
Page 14 of 48
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055047
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center
1010 Ventura Avenue
Chowchilla, CA 93610
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0700
Level of Harm - Immediate
jeopardy to resident health or
safety
Residents Affected - Some
indicated, .Physical Restraints .Physical restraints are any manual method, or physical or mechanical
device, material or equipment attached or adjacent to the resident's body that the individual cannot remove
easily which restricts freedom of movement or normal access to one's body .Bed rail 0 . MDSC stated, the
MDS section P was inaccurate because it was coded as 0 which meant not used. MDSC stated, he had
worked with Resident 55 in the past and stated he was non-verbal and had limited mobility.
During a concurrent observation and interview on 11/4/21, at 3:08 p.m., with MDSC, in Resident 55's room,
Resident 55 was laying in bed with both bed rails in the guard down position. MDSC stated, the quick
release knob was located on the bottom of the bed rail and Resident 55 would not be able to remove the
bed rail independently. MDSC proceeded to move the bed rail from its guard down position into the assist
up position (assisting the resident in standing or sitting in bed) and stated the assist bed rail should not be
down because there was no order, consent, care plan, or entrapment risk assessment. MDSC stated,
without an entrapment risk assessment the bed rails were an endangerment to Resident 55 and could
cause more harm than good.
During an interview on 11/4/21, at 3:38 p.m., with DOR, DOR stated when the therapy department makes a
recommendation for bed rail use a resident or resident representative consent was required prior to use.
DOR stated, if bed rails were installed just because a resident was a fall risk that would be considered a
restraint. DOR stated, there should be an entrapment risk assessment and care plan interventions for the
use of bed rails.
During an interview on 11/4/21, at 5:45 p.m., with DON, DON stated, the facility had different bed rail sizes.
DON stated, there was no determination of which residents' bed had longer or shorter bed rails, the bed
rails were installed based on whatever fit the bed.
During a review of the facility policy and procedure titled Bed Rails dated 11/2021 was reviewed. The policy
indicated .Decisions to use or discontinue the use of a bed rail will be made in the context of an
individualized resident assessment using an Interdisciplinary Team (IDT) and will take into account the
resident's medical needs, comfort, and freedom of movement .The Assessment of whether to use bed rails
should include an evaluation of the alternatives to the use of bed rail that were attempted and how these
alternatives failed to meet the resident's assessed needs. If bed rails are to bed used, the assessment Bed
Rail Utilization [would be conducted] by a Licensed Nurse and/or the IDT. The Licensed Nurse and/or the
IDT may refer to the Bed Rail Decision Tree during the assessment. Before installing a bed rail, the Facility
must: Assess the resident for risk for entrapment from bed rails; and Ensure the bed's dimensions are
appropriate for the resident's size and weight. If the bed rail is used as a restraint, the Facility will refer to
Policy Restraints, for informed procedures. If a bed rail is used as an enabler, the resident/resident
representative's informed consent will be obtained by a Licensed Nurse or the physician. The resident's
plan of care will be updated to reflect the use of bed rails. The plan of care should also include
documentation of the type of specific direct monitoring and supervision provided during the use of the bed
rails and the identification of how needs will be met during the use of bed rails .
During a review of the facility's P&P titled, Restraints, dated June 2020, the P&P indicated, .Physical
Restraint is defined as any manual method or physical or mechanical device, material, or equipment
attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom
of movement or normal access to one's body. This may include bed rails, .if underlying causes of medical
symptoms cannot be eliminated, alternative measures must be tried before a restraint is used .if the Facility
is utilizing bed rails, the assessment Bed Rail Entrapment Risk
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055047
If continuation sheet
Page 15 of 48
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055047
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center
1010 Ventura Avenue
Chowchilla, CA 93610
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0700
Level of Harm - Immediate
jeopardy to resident health or
safety
Residents Affected - Some
Assessment .will be completed by a Licensed Nurse prior to the installation of bed rails .if a bed rails is
being used as an enabler, the resident must be able to easily and voluntarily get in and out of bed when the
equipment is in use. If the resident cannot easily and voluntarily release the bed rails and/or use the bed
rails to reposition, the use of the bed rails may be considered a restraint .
During a review of the manufactured guidelines titled Assist Rails retrieved from
http://www.invacare.com/doc_files/1130185.pdf dated 1/26/2017 indicated, .The assist rails have three
positions: Guard (Down) A: This position is intended to prevent an individual from inadvertently rolling out of
bed. Assist (Up) B: Assist the user in the standing or sitting in bed. Transfer (Back) C: Allows unimpeded
access to user. When changing position of the assist rail, hold and raise the rail with one hand while pulling
the adjustment knob outward with the other hand .
During a review of professional reference from the FDA- Food and Drug Administration, titled A Guide to
Bed Safety Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts retrieved from
https://www.fda.gov/medical-devices/hospital-beds/guide-bed-safety-bed-rails-hospitals-nursing-homes-and-home-health-c
dated 12/11/17, indicated, . Today there are about 2.5 million hospital and nursing home beds in use in the
United States. Between 1985 and January 1, 2009, 803 incidents of patients* caught, trapped, entangled,
or strangled in beds with rails were reported to the U.S. Food and Drug Administration. Of these reports,
480 people died, 138 had a nonfatal injury, and 185 were not injured because staff intervened. Most
patients were frail, elderly or confused . Patients who have problems with memory, sleeping, incontinence,
pain, uncontrolled body movement, or who get out of bed and walk unsafely without assistance, must be
carefully assessed for the best ways to keep them from harm, such as falling. Assessment by the patient's
health care team will help to determine how best to keep the patient safe . Potential risks of bed rails may
include: Strangling, suffocating, bodily injury, or death when patients or part of their body are caught
between rails or between the bed rails and mattress. More serious injuries from falls when patients climb
over rails. Skin bruising, cuts, and scrapes. Inducing agitated behavior when bed rails are used as a
restraint. Feeling isolated or unnecessarily restricted. Preventing patients, who are able to get out of bed,
from performing routine activities such as going to the bathroom or retrieving something from a closet .
During a review of professional reference from the FDA- Food and Drug Administration, titled FDA
Entrapment Zones and Guidelines undated, indicated, . This product [bed rail] in not [is not] recommended
for individuals with cognitive problems (difficulty in understanding their surroundings) .
2. During an observation on 11/4/21, at 2:38 p.m., in Resident 16's room, Resident 16 was asleep in bed.
Resident 16 had a half beds rail on the upper left and upper right side of the bed in the guard position; the
right side of the bed was next to the wall.
During a concurrent interview and record review, on 11/4/21, at 3:38 p.m., with LVN 5, Resident 16's EHR
as reviewed. LVN 5 stated Resident 16 did not have a physician's order, Care Plan, and consent prior to the
use of bed rails. Resident 16's Enabler [a bed rails used to facilitate movement /Restraints-Physical [a
device used to impede movement] initial evaluation) was reviewed. The Enabler/Restraint-Physical (initial
evaluation), dated 6/1/18, indicated, .Reason for use of physical restraint . No restraints in use .
History/Alternatives Attempted . No restraints in use .Communication . Family/POA [Power of Attorney],
Decision Maker notified . No . Restraint Order . No .
During an interview on 11/4/21, at 3:38 p.m., with LVN 5, LVN 5 stated there should be a physician's order,
entrapment assessment, consent, and care plan prior to use of bed rails for Resident 16.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055047
If continuation sheet
Page 16 of 48
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055047
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center
1010 Ventura Avenue
Chowchilla, CA 93610
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0700
Level of Harm - Immediate
jeopardy to resident health or
safety
During a review of Resident 16's MDS and physical assessment dated [DATE], the MDS indicated Resident
16's BIMS score was 4 which indicated severe cognitive impairment. Resident 16's functional status
assessment indicated Resident 16 required two-person extensive assistance from staff with bed mobility.
3. During an observation on 11/4/21, at 2:42 p.m., in Resident 11's room, Resident 11 was asleep in bed.
Resident 11 had a half bed rail on the upper right and upper left side of the bed.
Residents Affected - Some
During a concurrent interview and record review, on 11/4/21, at 3:21 p.m. with LVN 5, Resident 11's
Physician's Order, dated 2/13/19 was reviewed. Resident 11's physician's order indicated, .side rail/enabler
bed mobility . Resident 11's Enabler/Restraint-Physical (initial evaluation), dated 1/11/19 was reviewed. The
Enabler/Restraint-Physical (initial evaluation) indicated, .Reason for use of physical restraint . No restraints
in use . History/Alternatives Attempted . No restraints in use . Communication . Family/POA [Power of
Attorney], Decision Maker notified . No . Restraint Order . No . Resident 11's Care Plan, dated 1/30/19 was
reviewed. Resident 11's care plan indicated, .I have physical functioning deficit related to: limited assistance
need with ADL's [Activities of Daily Living] . I will improve or maintain my current level of physical
functioning. Assistive devices (assist bar [a bed rail used to facilitate movement] to one side of the bed) .
LVN 5 stated Resident 11 had no consent prior to the use of the half bed rails .
During an interview on 11/4/21, at 3:38 p.m., with LVN 5, LVN 5 stated there should be a physician's order,
entrapment risk assessment, consent, and care plan prior to the use of bed rails for Resident 11.
4. During an observation on 11/4/21, at 2:50 p.m., in Resident 8's room, Resident 8 was asleep in bed.
Resident 8 had a half upper bed rails on both side of the bed in the guard position.
During a concurrent interview and record review, on 11/4/21, at 3:13 p.m., with LVN 5, Resident 8's EHR
was reviewed. LVN 5 stated Resident 8 did not have a physician's order, care plan, and entrapment risk
assessment prior to use of bed rails .
During an interview on 11/4/21, at 3:38 p.m., with LVN 5, LVN 5 stated there should be a physician's order,
entrapment assessment, consent, and care plan prior to use of bed rails for Resident 8.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055047
If continuation sheet
Page 17 of 48
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055047
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center
1010 Ventura Avenue
Chowchilla, CA 93610
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0725
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in
charge on each shift.
Based on interview and record review, the facility failed to provide sufficient staffing to provide care and
services to ensure residents received the needed care to attain and maintain their highest practicable
physical, mental and psychosocial well-being for five of six sampled residents (Residents 3, 10, 18, 19 and
20) when residents' needs, preferences, and accommodations were communicated to staff, and staff did
not respond in a timely manner.
These failures resulted in Residents 3, 10, 18, 19 and 20's needs not being met.
Findings:
During an interview on 11/2/21, at 2:56 p.m., with Resident 10, Resident 10 stated, the facility was
understaffed and would call for assistance which took up to an hour for staff to respond.
During an interview on 11/2/21, at 3:37 p.m., Resident 18's responsible party (RP), RP stated, she couldn't
remember how long ago it was that Resident 18 was not showered by staff for one and a half weeks.
During an interview on 11/3/21, at 9:19 a.m., with Certified Nursing Assistant (CNA) 7, CNA 7 stated, the
facility had problems keeping staff since COVID-19 (a contagious serious respiratory infection transmitted
from person to person) started in 2020. CNA 7 stated, she cared for 14-15 residents during the day and
there were times residents would miss there showers because of short staffing.
During an interview on 11/3/21, at 10:22 a.m., with Resident 19, Resident 19 stated, he required a lift to get
out of bed with staff's assistance and was unable to attend the resident council meetings regularly because
of short staffing.
During an interview on 11/3/21, at 10:28 a.m., with Resident 20, Resident 20 stated, the facility was
understaffed, and the resident's microwave was taken away from the residents because there was no staff
available to warm up the food such as popcorn.
During an interview on 11/3/21, at 10:30 p.m., with Resident 3, Resident 3 stated, the facility did not have
enough staff to meet all the resident's needs
During an interview on 11/10/21, at 11:32 a.m., with the Director of Staff Development (DSD), the DSD
stated, she was responsible for staffing CNAs, made the schedules, and filled call-ins when on shift. The
DSD stated, when she was not at the facility the Charge nurse would fill in the shifts as needed.
During a concurrent interview and record on 11/10/21, at 11:32 a.m., with the DSD, the facility document
titled Nursing Staffing Worksheet Patient Per Day (PPD) nursing hours for 8/21, 9/21, 10/21, and 11/21 was
reviewed. The DSD stated staffing had been difficult and the facility hardly ever met the required nursing
hours. The DSD stated, the facility did not have staffing waiver. The DSD stated, the staffing shortage
started with COVID-19 the facility became short staffed and had not been able to build their team. The DSD
stated, the facility had less staffing hours for the resident and that resident's would occasionally miss
showers. The DSD stated, the facility staffed 2 LVNs on am, pm and noc (night) shifts. The DSD stated, the
facility was not using a registry agency. The DSD
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055047
If continuation sheet
Page 18 of 48
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055047
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center
1010 Ventura Avenue
Chowchilla, CA 93610
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0725
stated, the facility had to do something because it was hard on the staff and hard on the residents.
Level of Harm - Minimal harm
or potential for actual harm
For 8/21 the facility had not met the minimum required nursing contact hours on 11 of 31 days.
For 9/21 the facility had not met the minimum required nursing contact hours on 21 of 30 days.
Residents Affected - Many
For 10/21 the facility had not met the minimum required nursing contact hours on 25 of 31 days
For 11/21 the facility had not met the minimum required nursing contact hours on 10 of 10 days
During an interview on 11/10/21, at 4:43 p.m., with the Administrator (ADM), the ADM stated, it was hard to
retain staff.
During an interview on 11/10/21, at 4:49 p.m., with the ADM, the ADM stated, staffing was discussed at
QAPI (Quality Assurance & Performance Improvement) meeting in September and there were no notes on
discussion of ideas to improve staffing. The ADM stated, the facility needed 6 CNA's to be fully staffed and
that staffing was the number 1 priority right now.
During a review of the facility policy titled Staffing dated 10/2017, indicated .Our facility provides sufficient
numbers of staff with the skills and competency necessary to provide care and services for all residents in
accordance with the resident care plans and the facility assessment .Staffing numbers and the skill
requirement of direct care staff are determined by the needs of the residents based on each resident's plan
of care .Inquiries or concerns relative to our facility's staffing should be directed to the Administrator or
his/her designee .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055047
If continuation sheet
Page 19 of 48
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055047
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center
1010 Ventura Avenue
Chowchilla, CA 93610
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0726
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way
that maximizes each resident's well being.
3. During a concurrent observation and interview on 11/2/21 at 2:26 p.m., with Resident 32, in Resident
32's room, Resident 32 was laying in bed with the catheter bag touching the ground. Resident 32 stated,
after lunch the Certified Nursing Assistant (CNA) emptied his catheter bag.
During a concurrent observation and interview on 11/2/21, at 2:35 p.m., with CNA 6, in Resident 32's room,
Resident 32's catheter bag was touching the ground. CNA 6 stated, the catheter bag should not be on the
ground because there was a risk for infection and cross contamination.
During a review of Resident 32's Care Plan, dated 11/2/21, the Care plan indicated, .Alteration in
elimination of bowel and bladder .Keep drainage bag of catheter below the level of the bladder at all times
and off floor .
During concurrent interview and record review on 11/3/21, at 3:46 p.m., with the DON, the facility policy and
procedure titled Catheter-Care of dated 6/2020 indicted, .Take care to ensure the collection bag does not
touch the floor at any time . The DON stated, the catheter bag should not touch the ground at any time
because it was an infection control issue.
During an interview on 11/09/21, at 1:48 p.m., with LVN 10, LVN 10 stated, she had been working at the
facility for four years and did not remember the last time she had an in-service training for urinary catheter
care.
During a concurrent interview and record review on 11/9/21, at 2:18 p.m., with the DSD, in-service titled
[facility name] of Chowchilla Meeting/In-Services dated 6/21/21 indicated, .Urinary tract infection (UTI) .If a
resident has a foley ensure that is anchored, and that the catheter remains below the level of the bladder .
The DSD reviewed the sign in sheet and stated, LVN 10's name was not on the sign in sheet and that LVN
10 did not have any competency in-service training for urinary catheter care.
Based on observation, interview and record review, the facility failed to ensure Licensed Nurses have the
competencies necessary to meet the needs of the residents for three of 43 sampled residents (Resident
110, 56 and 32) when:
1. Licensed Vocational Nurse (LVN) 8 administered insulin (medication used to treat high blood sugar) by
way of an insulin pen (a device used to inject insulin) to Resident 110 without priming (a method to remove
air bubbles from the pen to ensure it is working, and provides insulin full dose administration) the insulin
pen and without allowing the pen needle to remain under the skin for 5 to 10 seconds.
These failures placed Resident 110 at risk for an inaccurate insulin dosage and impaired insulin absorption
(movement of a medication from the site of administration to bloodstream).
2. LVN 3 administered insulin by way of an insulin pen to Resident 56 without disinfecting the insulin pen
rubber seal prior to attaching the needle, did not prime the insulin pen, and did not allow the pen needle to
remain under the skin for 5 to 10 seconds.
These failures placed Resident 56 at risk for an inaccurate insulin dosage and impaired insulin
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055047
If continuation sheet
Page 20 of 48
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055047
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center
1010 Ventura Avenue
Chowchilla, CA 93610
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0726
absorption and cross contamination.
Level of Harm - Minimal harm
or potential for actual harm
3. Resident 32's urinary catheter (a tube placed in the body to drain and collect urine from the bladder) bag
was touching the floor.
Residents Affected - Many
This failure placed Resident 32 at risk for cross contamination.
Findings:
1. During a medication administration observation, on 11/4/21, at 10:08 a.m., LVN 8 administered
NovoLOG insulin (rapid-acting insulin used to control high blood sugar in adults) 6 units (unit of
measurement) by way of an insulin pen to Resident 110. LVN 8 did not prime the NovoLOG insulin pen
prior to the insulin administration to Resident 110. LVN 8 injected the insulin to Resident 101's arm and
quickly removed the needle from Resident 110's arm without allowing the pen needle to remain under the
skin for 5 to 10 seconds.
During a review of Resident 110's, the admission Record (a document containing resident profile
information) dated 11/3/21, the admission Record indicated, Resident 110 was admitted to the facility with
diagnosis of Type 2 Diabetes Mellitus (a long-term disorder that is characterized by high blood sugar).
During a review of Resident 110, Order Summary Report dated 8/21/19, the Order Summary Report
indicated, Insulin NovoLOG Solution Inject as per sliding scale: 0-200 = 0; 201-250 = 2; 251-300 = 4; 400 =
6; 401- 450 = 8, subcutaneously (under the skin) one time a day related to Hyperglycemia (high blood
sugar in the blood).
During an interview on 11/4/21, at 10:11 a.m., with LVN 8, LVN 8 stated he did not prime the insulin pen,
and did not wait 5 seconds to remove the needle from Resident 110's arm after injection. LVN 8 stated he
had been a license nurse for 25 years and never heard of priming the insulin pen. LVN 8 stated he was not
provided in-service (education) on insulin pen administration.
During an interview with the Director of Staff Development (DSD), on 11/4/21, at 3:02 p.m., The DSD stated
she did not provide competencies for insulin pen administration to the license nurses.
During an interview with the Director of Nursing (DON), on 11/9/21, at 4:26 p.m., she stated the license
nurse should have primed the insulin pen prior to administration. The DON stated the nurse should have
kept the pen needle under the skin for 5 to 10 seconds after injecting the insulin to ensure the insulin was
absorbed.
During a review of the facility Policy and Procedure (P&P) titled Medication Administration Subcutaneous
Insulin dated 5/2016, the P&P indicated, . Always perform the safety test before each injection. Performing
the safety test ensures that you get an accurate dose by: ensuring that pen and the needle work properly.
Removing air bubbles . Hold the pen with the needle pointing upwards. Tap the insulin reservoir so that air
bubbles rise up towards the needle. Press the injection button all the way in. Check if insulin comes out of
the needle tip. You may have to perform the safety test several times before insulin seen. If no insulin comes
out, check for air bubbles and repeat the safety test two more times to remove them. If no insulin comes
out, the needle may be blocked .Deliver the dose by pressing the injection button in all the way . Keep the
injection button pressed all the way. Slowly count to 10 before you withdraw the needle from the skin. This
ensures that the full dose will
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055047
If continuation sheet
Page 21 of 48
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055047
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center
1010 Ventura Avenue
Chowchilla, CA 93610
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0726
be delivered .
Level of Harm - Minimal harm
or potential for actual harm
During a review of the facility document titled, Licensed Practical/Vocational Nurse JOB DESCRIPTION
undated, the Licensed Practical/Vocational Nurse JOB DESCRIPTION indicated, Principal Responsibilities
. Responsible for ensuring the delivery of efficient and effective nursing care while achieving positive clinical
outcomes and resident/family satisfaction in accordance with accepted standards of practice, stated and
federal regulations and licensing requirements . Ability to administer medications and treatment timely and
according to facility policy .
Residents Affected - Many
During a review of the facility document titled, Staff Development Coordinator JOB DESCRIPTION
undated, the Staff Development Coordinator JOB DESCRIPTION indicated, Responsible for planning,
implementing and maintaining of professional development in the clinical department in accordance with
current Federal, State and company standards, guidelines, and regulations. Demonstrates and teaches
resident care in classroom and clinical units to nursing staff . Assess the training of nursing staff to develop,
implement, evaluate and document staff development programs including General orientation, Job specific
Orientation, In-Service, and continuing Education Programs for nursing department personnel .
During a review of the facility document titled, Director of Nursing Job Description undated, the Director of
Nursing Job Description indicated, .Responsible for administration and management of Nursing Services to
residents in accordance with orders of the physician's and total needs of the residents. Responsible for
24-hour supervision of Nursing Services and directs the Nursing Department to maintain quality standards
of care in accordance with the current Federal, State and the Company standards guidelines and
regulations .Assumes ultimate responsibility for coordinating plans for total care of each residents which
comply with physician's order, government regulations, and facility resident care policies . Responsible for
competency testing on registered licensed, certified, non-certified nursing personnel .
During a review of the professional reference titled, Risk associated with the use of Insulin pens and Vials
dated 2017, found at
https://www.ismp.org/sites/default/files/attachments/2017-11/ISMP138-Insulin%20Guideline-051517-2-WEB.pdf),
indicated, . nurses have reported seeing a wet spot on the skin post injection due to insulin leaking from the
injection site because the needle was not left in place for 5-10 seconds after injection .
During a review of the professional reference titled, Severe hyperglycemia in patients incorrectly using
insulin pens at home dated 10/2017, (found at
https://www.ismp.org/alerts/severe-hyperglycemia-patients-incorrectly-using-insulin-pens-home), indicated,
. Prior to injection, the pen should be primed using 2 to 3 units of insulin to make certain that the needle is
correctly attached and to remove any air bubbles or pockets in the insulin cartridge. This is known as an air
shot and the patient should see about 2 drops of insulin come out of the needle .
2. During a medication administration observation, on 11/4/21, at 12:33 p.m., LVN 3 administered insulin
Lispro (fast-acting insulin used to control high blood sugar in adults) 5 units by way of an insulin pen to
Resident 56. LVN 3 did not disinfect the insulin pen rubber seal prior to attaching the needle and did not
prime the insulin Lispro pen prior to the insulin administration to Resident 56. LVN 3 injected the insulin on
to Resident 56's arm and quickly removed the needle from Resident 56's arm without allowing the pen
needle to remain under the skin for 5 seconds.
During an interview on 11/4/21, at 12:50 p.m., with LVN 3, LVN 3 stated she did not prime the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055047
If continuation sheet
Page 22 of 48
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055047
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center
1010 Ventura Avenue
Chowchilla, CA 93610
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0726
Level of Harm - Minimal harm
or potential for actual harm
insulin pen, and did not wait 5 seconds to remove the needle from Resident 56 after injection. LVN 3 stated
she was not provided in-service on insulin pen administration.
During a review of Resident 56, admission Record dated 1/17/20, the admission Record indicated,
Resident 56 was admitted to the facility with diagnosis of Type 2 Diabetes Mellitus.
Residents Affected - Many
During a review of Resident 56, Order Summary Report dated 10/12/21, the Order Summary Report
indicated, Insulin Lispro Solution Pen-Injector 100 UNIT/ML [milliliter] inject 5 unit subcutaneously with
meals related Type 2 Diabetes Mellitus .
During an interview with the Director of Staff Development (DSD), on 11/4/21, at 3:02 p.m., The DSD stated
she did not provide competencies for insulin pen administration to the license nurses.
During an interview with the Director of Nursing (DON), on 11/9/21, at 4:26 p.m., she stated the license
nurse should have primed the insulin pen prior to administration. The DON stated the nurse should have
kept the pen needle under the skin for 5 to 10 seconds after injecting the insulin to ensure the insulin was
absorbed. The DON stated the insulin pen rubber seal should be disinfected prior to attaching the needle to
prevent cross contamination.
During a review of the facility Policy and Procedure (P&P) titled Medication Administration Subcutaneous
Insulin dated 5/2016, the P&P indicated, . Always perform the safety test before each injection. Performing
the safety test ensures that you get an accurate dose by: ensuring that pen and the needle work properly.
Removing air bubbles . Hold the pen with the needle pointing upwards. Tap the insulin reservoir so that air
bubbles rise up towards the needle. Press the injection button all the way in. Check if insulin comes out of
the needle tip. You may have to perform the safety test several times before insulin seen. If no insulin comes
out, check for air bubbles and repeat the safety test two more times to remove them. If no insulin comes
out, the needle may be blocked .Deliver the dose by pressing the injection button in all the way . Keep the
injection button pressed all the way. Slowly count to 10 before you withdraw the needle from the skin. This
ensures that the full dose will be delivered .
During a review of the facility document titled, Licensed Practical/Vocational Nurse JOB DESCRIPTION
undated, the Licensed Practical/Vocational Nurse JOB DESCRIPTION indicated, Principal Responsibilities
. Responsible for ensuring the delivery of efficient and effective nursing care while achieving positive clinical
outcomes and resident/family satisfaction in accordance with accepted standards of practice, stated and
federal regulations and licensing requirements . Ability to administer medications and treatment timely and
according to facility policy .
During a review of the facility document titled, Staff Development Coordinator JOB DESCRIPTION
undated, the Staff Development Coordinator JOB DESCRIPTION indicated, Responsible for planning,
implementing and maintaining of professional development in the clinical department in accordance with
current Federal, State and company standards, guidelines, and regulations. Demonstrates and teaches
resident care in classroom and clinical units to nursing staff . Assess the training of nursing staff to develop,
implement, evaluate and document staff development programs including General orientation, Job specific
Orientation, In-Service, and continuing Education Programs for nursing department personnel .
During a review of the facility document titled, Director of Nursing Job Description undated, the Director of
Nursing Job Description indicated, .Responsible for administration and management of
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055047
If continuation sheet
Page 23 of 48
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055047
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center
1010 Ventura Avenue
Chowchilla, CA 93610
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0726
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Nursing Services to residents in accordance with orders of the physician's and total needs of the residents.
Responsible for 24-hour supervision of Nursing Services and directs the Nursing Department to maintain
quality standards of care in accordance with the current Federal, State and the Company standards
guidelines and regulations .Assumes ultimate responsibility for coordinating plans for total care of each
residents which comply with physician's order, government regulations, and facility resident care policies .
Responsible for competency testing on registered licensed, certified, non-certified nursing personnel .
During a review of the professional reference titled, Risk associated with the use of Insulin pens and Vials
dated 2017, found at
https://www.ismp.org/sites/default/files/attachments/2017-11/ISMP138-Insulin%20Guideline-051517-2-WEB.pdf),
indicated, . nurses have reported seeing a wet spot on the skin post injection due to insulin leaking from the
injection site because the needle was not left in place for 5-10 seconds after injection .
During a review of the professional reference titled, Severe hyperglycemia in patients incorrectly using
insulin pens at home dated 10/2017, (found at
https://www.ismp.org/alerts/severe-hyperglycemia-patients-incorrectly-using-insulin-pens-home), indicated,
. Prior to injection, the pen should be primed using 2 to 3 units of insulin to make certain that the needle is
correctly attached and to remove any air bubbles or pockets in the insulin cartridge. This is known as an air
shot and the patient should see about 2 drops of insulin come out of the needle .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055047
If continuation sheet
Page 24 of 48
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055047
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center
1010 Ventura Avenue
Chowchilla, CA 93610
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0759
Ensure medication error rates are not 5 percent or greater.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview and record review the facility failed to ensure the facility medication error
rate did not exceed five percent when the facility medication error rate was 16 percent when 25
opportunities of medication administration were observed and four of the 25 medications were not
administered in accordance with physician's orders, resulting in a medication error rate of 12 percent.
Residents Affected - Some
These failure placed Resident 110, and Resident 56 at risk for inaccurate insulin dosage and impaired
insulin absorption (movement of a medication from the site of administration to bloodstream) and not
getting the full therapeutic effects of all the administered medications.
Findings:
During a medication administration observation, on 11/04/21, at 10:09 a.m., in the hallway, with License
Vocational Nurse (LVN) 8, LVN 8 administered Sodium Bicarbonate (a medication use to relieve heartburn
and acid indigestion) tablet 650 mg (milligrams - unit of measurement) one tablet, Amoxicillin-Pot
Clavulanate (a medication use to treat infection) Tablet 500-125 mg one tablet, and NovoLOG insulin
(rapid-acting insulin used to control high blood sugar in adults) 6 units (unit of measurement) by way of an
insulin pen to Resident 110. LVN 8 did not prime (remove air bubbles from the needle to ensure it is open
and working) the NovoLOG insulin pen prior to the insulin administration to Resident 110. LVN 8 injected
the insulin to Resident 101's arm and quickly removed the needle from Resident 110's arm without allowing
the pen needle to remain under the skin for 5 seconds.
During an interview on 11/4/21, at 10:11 a.m., with LVN 8, LVN 8 stated he did not prime the insulin pen,
and did not wait 5 seconds to remove the needle from Resident 110 after injection. LVN 8 stated he had
been a license nurse for 25 years and never heard of priming the insulin pen.
During a review of Resident 110's admission Record (a document containing resident profile information)
dated 11/3/21, the admission Record indicated, Resident 110 was admitted to the facility with diagnoses of
Type 2 Diabetes Mellitus (a long-term disorder that is characterized by high blood sugar),
Gastroesophageal Reflux Disease (is the backward flow of stomach acid into the throat to the mouth), and
Osteomyelitis, Left ankle and foot (infection in the bones) .
During a review of Resident 110's Order Summary Report dated 8/21/19, the Order Summary Report
indicated, .Insulin NovoLOG Solution Inject as per sliding scale: 0-200 = 0; 201-250 = 2; 251-300 = 4; 400 =
6; 401- 450 = 8, subcutaneously (under the skin) one time a day related to Hyperglycemia (high blood
sugar in the blood) . Sodium Bicarbonate (used to relieve heartburn and acid indigestion.) Tablet 650 mg
(unit of measurment) Give 1 tablet by mouth three times a day related to Gastroesophageal Reflux Disease
. Amoxicillin-Pot Clavulanate (antibiotic) Tablet 500-125 mg Give 1 tablet by mouth two times a day for
Osteomyelitis for 7 days .
During a concurrent interview and record review, on 11/4/21, at 10:28 a.m., with LVN 8, Resident 110's
Medication Admin Audit Report (MAAR), dated 11/4/21 was reviewed. The MAAR indicated, . NovoLOG
Solution Inject as per sliding scale: 0-200 = 0; 201-250 = 2; 251-300 = 4; 400 = 6; 401- 450 = 8,
subcutaneously one time a day related to Hyperglycemia . Sliding scale PRN [as needed] only if BS [blood
sugar] is over 200 . Scheduled Date 11/4/21 07:00. Administration time 11/4/21 10:22 . Sodium Bicarbonate
Tablet 650 mg Give 1 tablet by mouth three times a day . Scheduled Date 11/4/21 07:00. Administration
time 11/4/21 10:22 . Amoxicillin-Pot Clavulanate Tablet 500-125 mg Give 1 tablet by mouth
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055047
If continuation sheet
Page 25 of 48
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055047
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center
1010 Ventura Avenue
Chowchilla, CA 93610
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0759
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
two times a day . Scheduled Date 11/4/21 07:00. Administration time 11/4/21 10:22 . LVN 8 stated the
medications was scheduled for 7 a.m. and was administered late at 10:22 a.m. to Resident 110.
During a medication administration observation, on 11/4/21, at 12:33 p.m., LVN 3 administered insulin
Lispro (fast-acting insulin used to control high blood sugar in adults) 5 units by way of an insulin pen to
Resident 56. LVN 3 did not disinfect the insulin pen rubber seal prior to attaching the needle and did not
prime the insulin Lispro pen prior to insulin administration to Resident 56. LVN 3 injected the insulin on to
Resident 56's arm and quickly removed the needle from Resident 56's arm without allowing the pen needle
to remain under the skin for 5 to 10 seconds.
During an interview on 11/4/21, at 12:50 p.m., with LVN 3, LVN 3 stated she did not prime the insulin pen,
and did not wait 5 to 10 seconds to remove the needle from Resident 56 arm after injection.
During a review of Resident 56, admission Record dated 1/17/20, the admission Record indicated,
Resident 56 was admitted to the facility with diagnosis of Type 2 Diabetes Mellitus.
During a review of Resident 56, Order Summary Report dated 10/12/21, the Order Summary Report
indicated, Insulin Lispro Solution Pen-Injector 100 UNIT/ML [milliliter] inject 5 unit subcutaneously with
meals related Type 2 Diabetes Mellitus .
During an interview with the Director of Nursing (DON), on 11/9/21, at 4:26 p.m., she stated the license
nurse should have primed the insulin pen prior to administration to Resident 110 and Resident 56. The
DON stated the nurse should have kept the pen needle under the skin for 5 to 10 seconds after injecting
the insulin to ensure the insulin was absorbed and Resident 110 and Resident 56 receive the accurate
insulin dose. The DON stated the license nurse should administered medications in a timely manner to
ensure the effectiveness of the medications.
During a review of the facility document titled, Licensed Practical/Vocational Nurse JOB DESCRIPTION
undated, indicated, Principal Responsibilities . Responsible for ensuring the delivery of efficient and
effective nursing care while achieving positive clinical outcomes and resident/family satisfaction in
accordance with accepted standards of practice, stated and federal regulations and licensing requirements
. Ability to administer medications and treatment timely and according to facility policy .
During a review of the facility Policy and Procedure (P&P) titled Medication Administration Subcutaneous
Insulin dated 5/2016, the P&P indicated, . Always perform the safety test before each injection. Performing
the safety test ensures that you get an accurate dose by: ensuring that pen and the needle work properly.
Removing air bubbles . Hold the pen with the needle pointing upwards. Tap the insulin reservoir so that air
bubbles rise up towards the needle. Press the injection button all the way in. Check if insulin comes out of
the needle tip. You may have to perform the safety test several times before insulin seen. If no insulin comes
out, check for air bubbles and repeat the safety test two more times to remove them. If no insulin comes
out, the needle may be blocked .Deliver the dose by pressing the injection button in all the way . Keep the
injection button pressed all the way. Slowly count to 10 before you withdraw the needle from the skin. This
ensures that the full dose will be delivered .
During a review of the facility Policy and Procedure (P&P) titled Medication Administration General
Guidelines dated 9/2018, the P&P indicated, .Medications are administered in accordance with written
orders of the prescriber . Medications are administered within 60 minutes of scheduled time .
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055047
If continuation sheet
Page 26 of 48
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055047
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center
1010 Ventura Avenue
Chowchilla, CA 93610
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0759
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
During a review of the professional reference titled, Using medication: Using antibiotics[medications use to
treat infections] correctly and avoiding resistance dated 11/2008, retrieved from
https://www.ncbi.nlm.nih.gov/books/NBK361005/, indicated, .When should you take antibiotics? Some
antibiotics are always meant to be taken at the same time of day, others are meant to be taken before, with
or after a meal. If you are supposed to take the medicine three times a day, for example, it usually needs to
be taken at set times so that the effect is spread out evenly over the course of the day .
During a review of the professional reference titled, Why You Need to Take Your Medications as Prescribed
or Instructed dated 2/2016 retrieved from
https://www.fda.gov/drugs/special-features/why-you-need-take-your-medications-prescribed-or-instructed,
indicated, . Sticking to your medication routine (or medication adherence) means taking your medications
as prescribed - the right dose, at the right time, in the right way and frequency. Why is doing these things
important? Simply put, not taking your medicine as prescribed by a doctor or instructed by a pharmacist
could lead to your disease getting worse, hospitalization, even death .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055047
If continuation sheet
Page 27 of 48
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055047
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center
1010 Ventura Avenue
Chowchilla, CA 93610
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0760
Ensure that residents are free from significant medication errors.
Level of Harm - Minimal harm
or potential for actual harm
Based on Observation, Interview, and Record Review the facility failed to ensure residents were free from
significant medication error for two of six sampled residents (Resident 110, and Resident 56) when:
Residents Affected - Some
1. Licensed Vocational Nurse (LVN) 8 administered Amoxicillin-Pot Clavulanate (a medication use to treat
infection) not following physician's order administration time, and administered insulin (medication used to
treat high blood sugar) by way of an insulin pen (a device used to inject insulin) to Resident 110 without
priming prime (a method to remove air bubbles from the needle to ensure it is working, and provides insulin
full dose administration) the insulin pen and without allowing the pen needle to remain under the skin for 5
to 10 seconds.
2. LVN 3 administered insulin by way of an insulin pen to Resident 56 without disinfecting the insulin pen
rubber seal prior to attaching the needle, did not prime the insulin pen, and did not allow the pen needle to
remain under the skin for 5 to 10 seconds.
These failure placed Resident 110, and Resident 56 at risk for inaccurate insulin dosage and impaired
insulin absorption (movement of a medication from the site of administration to bloodstream) and not
getting the full therapeutic effects of the administered medications.
Findings:
1. During a medication administration observation, on 11/04/21, at 10:09 a.m., in the hallway, with License
Vocational Nurse (LVN) 8, LVN 8 administered Amoxicillin-Pot Clavulanate (antibiotic) Tablet 500-125 mg
(milligrams - unit of measurement) one tablet, and NovoLOG insulin (rapid-acting insulin used to control
high blood sugar in adults) 6 units (unit of measurement) by way of an insulin pen to Resident 110. LVN 8
did not the NovoLOG insulin pen prior to the insulin administration to Resident 110. LVN 8 injected the
insulin to Resident 101's arm and quickly removed the needle from Resident 110's arm without allowing the
pen needle to remain under the skin for at least 5 seconds.
During an interview on 11/4/21, at 10:11 a.m., with LVN 8, LVN 8 stated he did not prime the insulin pen,
and did not wait 5 seconds to remove the needle from Resident 110's arm after injection. LVN 8 stated he
had been a license nurse for 25 years and never heard of priming the insulin pen.
During a review of Resident 110's admission Record (a document containing resident profile information)
dated 11/3/21, the admission Record indicated, Resident 110 was admitted to the facility with diagnoses of
Type 2 Diabetes Mellitus (a long-term disorder that is characterized by high blood sugar),
Gastroesophageal Reflux Disease (is the backward flow of stomach acid into the throat to the mouth), and
Osteomyelitis, Left ankle and foot (infection in the bones) .
During a review of Resident 110's Order Summary Report dated 8/21/19, the Order Summary Report
indicated, .Insulin NovoLOG Solution Inject as per sliding scale: 0-200 = 0; 201-250 = 2; 251-300 = 4; 400 =
6; 401- 450 = 8, subcutaneously (under the skin) one time a day related to Hyperglycemia (high blood
sugar in the blood) . Amoxicillin-Pot Clavulanate Tablet 500-125 mg Give 1 tablet by mouth two times a day
for Osteomyelitis for 7 days .
During a concurrent interview and record review, on 11/4/21, at 10:28 a.m., with LVN 8, Resident 110's
Medication Admin Audit Report (MAAR), dated 11/4/21 was reviewed. The MAAR indicated, . NovoLOG
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055047
If continuation sheet
Page 28 of 48
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055047
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center
1010 Ventura Avenue
Chowchilla, CA 93610
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0760
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Solution Inject as per sliding scale: 0-200 = 0; 201-250 = 2; 251-300 = 4; 400 = 6; 401- 450 = 8,
subcutaneously one time a day related to Hyperglycemia . Sliding scale PRN [as needed] only if BS [blood
sugar] is over 200 . Scheduled Date 11/4/21 07:00. Administration time 11/4/21 10:22 . Amoxicillin-Pot
Clavulanate Tablet 500-125 mg Give 1 tablet by mouth two times a day . Scheduled Date 11/4/21 07:00.
Administration time 11/4/21 10:22 . LVN 8 stated the medications was scheduled for 7 a.m. and was
administered late at 10:22 a.m. to Resident 110.
During an interview with the Director of Nursing (DON), on 11/9/21, at 4:26 p.m., she stated the license
nurse should have primed the insulin pen prior to administration to Resident 110 and Resident 56. The
DON stated the nurse should have kept the pen needle under the skin for 5 to 10 seconds after injecting
the insulin to ensure the insulin was absorbed and Resident 110 and Resident 56 receive the accurate
insulin dose. The DON stated the license nurse should administered medications in a timely manner to
ensure the effectiveness of medicatiuons.
During a review of the facility document titled, Licensed Practical/Vocational Nurse JOB DESCRIPTION
undated, indicated, .Principal Responsibilities . Responsible for ensuring the delivery of efficient and
effective nursing care while achieving positive clinical outcomes and resident/family satisfaction in
accordance with accepted standards of practice, stated and federal regulations and licensing requirements
. Ability to administer medications and treatment timely and according to facility policy .
During a review of the facility Policy and Procedure (P&P) titled Medication Administration Subcutaneous
Insulin dated 5/2016, the P&P indicated, . Always perform the safety test before each injection. Performing
the safety test ensures that you get an accurate dose by: ensuring that pen and the needle work properly.
Removing air bubbles . Hold the pen with the needle pointing upwards. Tap the insulin reservoir so that air
bubbles rise up towards the needle. Press the injection button all the way in. Check if insulin comes out of
the needle tip. You may have to perform the safety test several times before insulin seen. If no insulin comes
out, check for air bubbles and repeat the safety test two more times to remove them. If no insulin comes
out, the needle may be blocked .Deliver the dose by pressing the injection button in all the way . Keep the
injection button pressed all the way. Slowly count to 10 before you withdraw the needle from the skin. This
ensures that the full dose will be delivered .
During a review of the facility Policy and Procedure (P&P) titled Medication Administration General
Guidelines dated 9/2018, the P&P indicated, .Medications are administered in accordance with written
orders of the prescriber . Medications are administered within 60 minutes of scheduled time .
During a review of the professional reference titled, Using medication: Using antibiotics[medications use to
treat infections] correctly and avoiding resistance dated 11/2008, retrieved from
https://www.ncbi.nlm.nih.gov/books/NBK361005/, indicated, .When should you take antibiotics? Some
antibiotics are always meant to be taken at the same time of day, others are meant to be taken before, with
or after a meal. If you are supposed to take the medicine three times a day, for example, it usually needs to
be taken at set times so that the effect is spread out evenly over the course of the day .
During a review of the professional reference titled, Why You Need to Take Your Medications as Prescribed
or Instructed dated 2/2016 retrieved from
https://www.fda.gov/drugs/special-features/why-you-need-take-your-medications-prescribed-or-instructed,
indicated, . Sticking to your medication routine (or medication adherence) means taking your medications
as prescribed - the right dose, at the right time, in the right way and frequency. Why is doing these things
important? Simply put, not taking
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055047
If continuation sheet
Page 29 of 48
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055047
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center
1010 Ventura Avenue
Chowchilla, CA 93610
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0760
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
your medicine as prescribed by a doctor or instructed by a pharmacist could lead to your disease getting
worse, hospitalization, even death .
2. During a medication administration observation, on 11/4/21, at 12:33 p.m., LVN 3 administered insulin
Lispro (fast-acting insulin used to control high blood sugar in adults) 5 units by way of an insulin pen to
Resident 56. LVN 3 did not disinfect the insulin pen rubber seal prior to attaching the needle and did not
prime the insulin Lispro pen prior to insulin administration to Resident 56. LVN 3 injected the insulin on to
Resident 56's arm and quickly removed the needle from Resident 56's arm without allowing the pen needle
to remain under the skin for 5 to 10 seconds.
During an interview on 11/4/21, at 12:50 p.m., with LVN 3, LVN 3 stated she did not prime the insulin pen,
and did not wait 5 to 10 seconds to remove the needle from Resident 56 arm after injection.
During a review of Resident 56, admission Record dated 1/17/20, the admission Record indicated,
Resident 56 was admitted to the facility with diagnosis of Type 2 Diabetes Mellitus.
During a review of Resident 56, Order Summary Report dated 10/12/21, the Order Summary Report
indicated, Insulin Lispro Solution Pen-Injector 100 UNIT/ML [milliliter] inject 5 unit subcutaneously with
meals related Type 2 Diabetes Mellitus .
During an interview with the Director of Nursing (DON), on 11/9/21, at 4:26 p.m., she stated the license
nurse should have primed the insulin pen prior to administration to Resident 110 and Resident 56. The
DON stated the nurse should have kept the pen needle under the skin for 5 to 10 seconds after injecting
the insulin to ensure the insulin was absorbed and Resident 110 and Resident 56 receive the accurate
insulin dose. The DON stated the license nurse should administered medications in a timely manner to
ensure effectiveness of the medications.
During a review of the facility document titled, Licensed Practical/Vocational Nurse JOB DESCRIPTION
undated, indicated, Principal Responsibilities . Responsible for ensuring the delivery of efficient and
effective nursing care while achieving positive clinical outcomes and resident/family satisfaction in
accordance with accepted standards of practice, stated and federal regulations and licensing requirements
. Ability to administer medications and treatment timely and according to facility policy .
During a review of the facility Policy and Procedure (P&P) titled Medication Administration Subcutaneous
Insulin dated 5/2016, the P&P indicated, . Always perform the safety test before each injection. Performing
the safety test ensures that you get an accurate dose by: ensuring that pen and the needle work properly.
Removing air bubbles . Hold the pen with the needle pointing upwards. Tap the insulin reservoir so that air
bubbles rise up towards the needle. Press the injection button all the way in. Check if insulin comes out of
the needle tip. You may have to perform the safety test several times before insulin seen. If no insulin comes
out, check for air bubbles and repeat the safety test two more times to remove them. If no insulin comes
out, the needle may be blocked .Deliver the dose by pressing the injection button in all the way . Keep the
injection button pressed all the way. Slowly count to 10 before you withdraw the needle from the skin. This
ensures that the full dose will be delivered .
During a review of the facility Policy and Procedure (P&P) titled Medication Administration General
Guidelines dated 9/2018, the P&P indicated, .
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055047
If continuation sheet
Page 30 of 48
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055047
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center
1010 Ventura Avenue
Chowchilla, CA 93610
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0760
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Medications are administered in accordance with written orders of the prescriber . Medications are
administered within 60 minutes of scheduled time .
During a review of the professional reference titled, Why You Need to Take Your Medications as Prescribed
or Instructed dated 2/2016 retrieved from
https://www.fda.gov/drugs/special-features/why-you-need-take-your-medications-prescribed-or-instructed,
indicated, . Sticking to your medication routine (or medication adherence) means taking your medications
as prescribed - the right dose, at the right time, in the right way and frequency. Why is doing these things
important? Simply put, not taking your medicine as prescribed by a doctor or instructed by a pharmacist
could lead to your disease getting worse, hospitalization, even death .
Event ID:
Facility ID:
055047
If continuation sheet
Page 31 of 48
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055047
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center
1010 Ventura Avenue
Chowchilla, CA 93610
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
Based on observation, interview and record review, the facility failed to ensure drugs were labeled in
accordance with currently accepted professional standards of practice for one of 43 sampled residents
(Resident 2) when Resident 2's artificial eye drops container was stored in the medication cart in the
hallway without an open and used by date.
These failures had the potential to result in the contamination, decreased efficacy of eye drops which
placed Resident 2 at risk for decrease eye moisture and getting an eye infection.
Findings:
During a concurrent observation and interview, on 11/4/21, at 9:16 a.m., with License Vocational Nurse
(LVN) 2, the medication cart stored Resident 2's artificial sterile eye drops. The eye drops had no open date
and used by date (last date recommended for the use of a product while at peak quality) and was ready for
Resident 2's use. LVN 2 stated the artificial sterile eye drop once open should have an open date and used
by date to ensure medication potency and prevent eye infection.
During an interview on 11/9/21 at 4:26 p.m., with the Director of Nursing (DON), the DON stated Resident
2's eye drops once open should have an open and used by date to ensure medication potency.
During a review of the facility policy and procedure (P&P) titled, Medication Administration dated 9/2019,
the P&P indicated, . Certain products of package types such as . ophthalmic drops have specified
shortened end-of-use dating, once opened, to ensure medication purity and potency . Position statements
from the American Society of Ophthalmic Registered Nurses and American Society of Cataract &
Refractive Surgery (ASCRS) stated that multi-use eye drops and ointments should be disposed of 28 days
after initial use. These position statements are based on safety guidelines that have been established for
safe use and are considered as best practice .
The Ocular Surface, Professional Reference titled, A Patient's Guide to Artificial Tears dated 8/3/17, (found
at http://www.tearfilm.org/dettnews-a_patients_guide_to_artificial_tears/5523_5519/eng/) indicated . As
soon as you open . bottle, bacteria or fungus free-floating in the air will inevitably get in . In addition, many
people use artificial tears in an as needed manner . increasing risk of contamination. A good practice . is
that once you open a bottle, label it with the date of opening, and discard after 3 months even if it's not
finished .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055047
If continuation sheet
Page 32 of 48
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055047
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center
1010 Ventura Avenue
Chowchilla, CA 93610
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0802
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition
service.
Based on observations, interviews and record reviews, the facility failed to ensure the food service staff had
the appropriate competencies and skills sets to carry out the functions of the food service when one of
seven dietary staff (Cook-CK 4) worked in the kitchen with an expired food handler card (FHC-proof of
certification required of all food handlers in certain states within the United States. A food handler is defined
as a person who works in a food facility and performs any duties that involve the preparation, storage or
service of food in a facility).
This failure had the potential to place residents at risk for unsafe food practices and handling which may
lead to food borne illnesses (is any illness resulting from the spoilage of contaminated food, pathogenic
bacteria, viruses, or parasites that contaminate food).
Findings:
During a concurrent interview and record review, on 11/05/21, at 10:23 a.m., with Dietary Supervisor (DS),
the [NAME] (CK) 4, DS, CK 1, Dietary Aide (DA) 1, CK 3, DA 2 and CK 2's FHCs were reviewed. CK 4's
FHC was issued on 6/11/2018 and expired on 6/10/21. DS stated a current FHC was expected to work in
the kitchen. DS stated residents could develop food borne illnesses if dietary staff was not current on safe
food handling practices.
During a concurrent interview and record review, on 11/05/21, at 10:45 a.m., with CK 4, the FHC was
reviewed. The FHC indicated, CK 4's certificate expired on 6/10/2021. CK 4 stated she knew her FHC was
expired. CK 4 stated residents in the facility could develop food borne illnesses because she was not up to
date on the current food practices and standards of food handling.
During an interview on 11/05/21, at 1:36 p.m., with Registered Dietician (RD-a skilled health care
professional who is an expert in the field of nutrition), RD stated she performed an audit and was aware
that one of the staff did not have a current FHC. RD stated it is an expectation for the dietary staff to follow
the current standard food handling and must have a current FHC. RD stated the residents could get food
borne illnesses if residents' food was not handled properly and staff were not current on safe food
practices.
During a review of CK 4's Timecard, dated 6/1/2021 through 10/22/2021, the Timecard indicated, CK 4
worked fulltime at the facility after the food FHC had expired.
During an interview on 11/05/21, at 4:08 p.m., with the Administrator (ADM), the ADM stated the DS was
responsible for oversight of dietary staff. The ADM stated her expectation was for all dietary staff not to
work unless have an active FHC to work in the kitchen.
During a review of the Health and Safety Code 113948 (HSC), dated 1/1/2020, the HSC indicated, .Each
food handler shall maintain a valid food handler card for the duration of his or her employment as a food
handler .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055047
If continuation sheet
Page 33 of 48
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055047
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center
1010 Ventura Avenue
Chowchilla, CA 93610
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interview and record review, the facility failed to store, prepare, and serve food in
accordance with professional standards for food safety when two spices were expired, one applesauce
container was not labeled and did not contain the use by date (last date recommended for the use of a
product while at peak quality). These food items were available in the kitchen for use to prepare food for 57
out of 57 residents.
This failure placed 57 residents at risk for foodborne illnesses (illnesses caused by consuming
contaminated food or drink) from consuming potentially contaminated food (unclean) and exposure to
harmful pathogens (bacteria or viruses that can cause illness) and decrease palatability of the food.
Findings:
During a concurrent observation and interview on 11/2/21, at 11:13 a.m., with Dietary Supervisor (DS), in
the kitchen, the refrigerator had a small container of applesauce that had the open date of 10/30/21 and
due date of 11/1/21. The DS stated the applesauce should not be used after the written date on the
container. The DS threw away the applesauce. There were 2 spices on the shelf: The container of ground all
spice had an open date of 10/28/20 and expiration date of 10/28/21 written on the container. The container
of oregano had a written opened date of 4/27/21 and an expiration date of 10/27/21. The DS stated the
spices should have been discarded after the expiration date. The DS stated that expired spices and food
could cause food borne illnesses and change the taste of a resident's food.
During an interview on 11/4/21 at 10:00 a.m. with [NAME] (CK) 1, CK 1 stated expired spices added to food
could cause a bad taste for residents. CK1 stated expired applesauce could cause residents to get sick.
During an interview on 11/4/21, at 10:10 a.m. with the DS, the DS stated the evening shift staff was
responsible for making sure there was no expired food in the kitchen.
During a concurrent interview and record review, on 11/5/21, at 12:02 p.m., with DS, the policy and
procedure (P&P) titled, Canned and Dry Goods Storage, dated 2018 was reviewed. The P&P indicated, .All
opened food items will have an open and use-by-date .Spices (ground) 6-12 months . The DS stated the
spices should have been discarded after the expiration date.
During a phone interview on 11/05/21, at 1:36 p.m., with the Registered Dietician (RD-a skilled health care
professional who is an expert in the field of nutrition), RD stated that it is the responsibility of all staff that
works in the kitchen to check for expired food items. RD stated expired spices and applesauce could
compromise residents' health status and could change the palatability of food or make the resident
potentially sick. The RD stated it should not be the standard of food handling in the kitchen. RD stated the
kitchen staff should follow the facility's P&P.
During an interview on 11/10/21, at 12:20 p.m., with the ADM, ADM stated it was DS's responsibility to
check foods in kitchen for the use by or expiration dates.
During a review of Food Safety and Inspection Service titled Food Product Dating undated, indicated, .If a
product has a use by date, follow that date
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055047
If continuation sheet
Page 34 of 48
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055047
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center
1010 Ventura Avenue
Chowchilla, CA 93610
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
During a review of the professional reference titled USDA Food Safety and Inspection Service's Food
Product Dating retrieved from
https://www.fsis.usda.gov/food-safety/safe-food-handling-and-preparation/food-safety-basics/food-product-dating
dated 10/2/2019, indicated, .Microorganisms such as molds, yeasts, and bacteria can multiply and cause
food to spoil. Viruses are not capable of growing in food and do not cause spoilage. There are two types of
bacteria that can be found on food: pathogenic bacteria, which cause foodborne illness, and spoilage
bacteria, which do not cause illness but do cause foods to deteriorate and develop unpleasant
characteristics such as an undesirable taste or odor making the food not wholesome. When spoilage
bacteria have nutrients (food), moisture, time, and favorable temperatures, these conditions will allow the
bacteria to grow rapidly and affect the quality of the food. Food spoilage can occur much faster if food is not
stored or handled properly .
Event ID:
Facility ID:
055047
If continuation sheet
Page 35 of 48
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055047
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center
1010 Ventura Avenue
Chowchilla, CA 93610
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0813
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review, the facility failed to develop a policy and procedure allowing
residents to have outside food brought in by the family and/or visitors ensuring sanitary and safe food
storage for six of six sampled residents (18, 19, 35, and 51) when residents were informed, they were not
allowed to store and/or reheat prepared food brought to them by family.
Residents Affected - Many
This failure had the potential for unsafe and unsanitary food storage and handling brought from outside for
later consumption and placed Residents 18, 19. 35 and 51at high risk for food borne illnesses.
Findings:
During a concurrent observation and interview on 11/02/21, at 3:37 p.m., with Resident 18 and Resident
18's Responsible Party (RP) 2, RP 2 brought in carrot cake. Resident 18's RP 2 stated food could be
brought in for Resident 18, if eaten during the visit. Resident 18's RP 2 stated there was no refrigerator to
store foods brought from home.
During Resident Council Meeting (an organized group of residents who meet regularly to discuss concerns
about their rights) and interviews on 11/03/21, at 10:36 a.m., with Residents 18, 19, 35 and 51, Residents
18, 19, 35 and 51 stated they were not allowed to use the microwave or store any personal foods in the
facility's refrigerator.
During a concurrent observation and interview on 11/04/21, at 10:13 a.m., with the Dietary Supervisor
(DS), the DS stated residents were not allowed to bring anything that need to be microwaved or cooked.
The DS stated residents were supposed to keep the foods in their room. DS stated food could not be kept
in the kitchen. The DS stated there was no space to put the residents' foods in the facility's refrigerators.
The DS stated the Activities Director (AD-oversees the therapeutic and recreational activities) was
responsible for not allowing to use the microwave or store any personal foods in the facility's refrigerator.
The DS stated former residents misused the microwave in the past.
During an interview on 11/04/21, at 10:33 a.m. with the AD, the AD stated that families can bring food to
residents from the outside. AD stated the facility would like the resident to eat the food brought to them
during their visit. AD stated the food must be discarded after two hours if the food is not eaten.
During an interview on 11/05/21, at 1:36 p.m., with Registered Dietician (RD-a skilled health care
professional who is an expert in the field of nutrition), the RD stated there was no space in the facility
refrigerators to store the residents' foods from outside. RD stated food left at room temperature had the
potential to grow bacteria which could lead to food borne illnesses.
During an interview on 11/5/21, at 4:08 p.m., with the Administrator (ADM), the ADM stated that the facility
had a policy and procedure titled Food brought in by visitors. ADM stated the policy was current even
though there was a part of the policy that is marked through with a permanent marker. The ADM stated she
knew the residents had the right to bring in food, but the facility did not have space to refrigerate them.
During a review of the facility policy and procedure (P&P) titled, Food Brought in by Visitors, dated 8/2020,
indicated, .Perishable food requiring refrigeration will be discarded after two hours at
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055047
If continuation sheet
Page 36 of 48
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055047
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center
1010 Ventura Avenue
Chowchilla, CA 93610
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0813
bedside .
Level of Harm - Minimal harm
or potential for actual harm
During a review of the Center for Disease Control and Prevention (CDC) Guideline titled Four Steps to
Food Safety: Clean, Separate, Cook, Chill, dated 10/15/21, The Guideline indicated, .Bacteria can multiply
rapidly if left at room temperature or in the Danger Zone between 40°F and 140°F. Never leave
perishable food out for more than 2 hours (or 1 hour if exposed to temperatures above 90°F) .
Residents Affected - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055047
If continuation sheet
Page 37 of 48
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055047
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center
1010 Ventura Avenue
Chowchilla, CA 93610
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0835
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview, and record review, the facility's Administrator (ADM) failed to ensure effective oversight
and necessary resources to ensure resident care services were met to attain or maintain the highest
practicable physical, mental, and psychosocial well-being of each resident when the ADM did not provide
oversight to the facility's day to day operations when:
Residents Affected - Many
1. The facility failed to ensure five of five Residents (Residents 6, 8, 11, 16, and 55) were assessed for the
risk of entrapment (resident caught, trapped, or entangled in the space in or about the bed and side rail)
from bed (side) rails (adjustable metal or rigid plastic bars in various sizes that attach to the bed, and can
be placed in a guard (raised) or lowered) prior to installation and had no consent (form signed by resident
or family explaining the risks of side rail use), physician order, indication for use, and care plans prior to the
use of side rails.
These failures had the potential to cause entrapment, serious harm, injury, or death to Residents 6, 8, 11,
16, and 55. (Cross reference F700).
2. Licensed Vocational Nurses (LVN) 8 and LVN 7 did not receive annual competency training on insulin
pen administration and administered insulin (medication used to treat high blood sugar) by way of an insulin
pen (a device used to inject insulin) to Resident 110 and Resident 56 without disinfecting the insulin pen
rubber seal prior to attaching the needle, did not prime (a method to remove air bubbles from the pen to
ensure it is working, and provides insulin full dose administration) the insulin pen and did not allow the pen
needle to remain under the skin for 5 to 10 seconds.
These failure placed Resident 110 and Resident 56 at risk for an inaccurate insulin dosage and impaired
insulin absorption (movement of a medication from the site of administration to bloodstream) and cross
contamination. (Cross reference 726).
3. The facility failed to ensure the designated Infection Preventionist (IP-professional who ensures
healthcare workers and patients are doing all the things they should to prevent infections) completed the
specialized training for IP certification program in accordance with the facility's policy and procedure and
CMS (Centers for Medicare and Medicaid Services) guidelines.
This failure resulted in the IP not meeting the qualifications that would ensure residents were provided with
quality care to prevent or minimize the transmission or spread of COVID-19 (a contagious serious
respiratory infection transmitted from person to person) and/or other infections to all residents and staff.
(Cross reference F882).
4. LVN 6 did not receive annual mandatory training on Abuse Prevention and HIPPA (Health Insurance
Portability and Accountability Act- is a federal law that required the creation of national standards to protect
sensitive patient health information from being disclosed without the patient's consent or knowledge)
training for 2020 and 2021, and Certified Nursing Assistant (CNA) 1 did not have HIPPA training for 2020
and 2021.
These failure had the potential for the residents to be cared for by LVN's and CNAs' inadequately trained.
5. The ADM was aware of the facility's staffing needs and did not implement interventions to
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055047
If continuation sheet
Page 38 of 48
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055047
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center
1010 Ventura Avenue
Chowchilla, CA 93610
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0835
address the facility staffing needs.
Level of Harm - Minimal harm
or potential for actual harm
This failure had the potential for all residents needs not being met.
Findings:
Residents Affected - Many
1. During an interview on 11/10/21 at 4:43 p.m., with the ADM, the ADM stated staff yearly competencies
were not discussed in Quality Assurance and Performance Improvement (QAPI- is a data driven and
pro-active approach to quality improvement). The ADM stated restraint competency had not been done in 2
years. The ADM stated the used of bed rails as restraints was a bigger systemic facility issue.
During a review of the facility document titled, Administrator undated, indicated, The Administrator oversees
the day to day operations of the facility to meet State and Federal regulations and supervise all department
managers to ensure the facility is in compliance. The Administrator is responsible for the delivery of clinical
service . meeting or exceeding quality . Ensures the highest quality in Standards of Care and services
provided . Conducts continuing education programs and special in-service training to all departments'
managers and special in-service for all staff .
2. During an interview with the Director of Staff Development (DSD), on 11/4/21, at 3:02 p.m., The DSD
stated she did not provide competencies for insulin pen administration to the license nurses.
During a review of the facility document titled, Staff Development Coordinator JOB DESCRIPTION
undated, the Staff Development Coordinator JOB DESCRIPTION indicated, Responsible for planning,
implementing and maintaining of professional development in the clinical department in accordance with
current Federal, State and company standards, guidelines, and regulations. Demonstrates and teaches
resident care in classroom and clinical units to nursing staff . Assess the training of nursing staff to develop,
implement, evaluate and document staff development programs including General orientation, Job specific
Orientation, In-Service, and continuing Education Programs for nursing department personnel .
During an interview on 11/10/21 at 4:43 p.m., with the Admistartor (ADM), the ADM stated staff annual
mandatory training and nursing competencies was not discussed during QAPI. The ADM stated nursing
staff should receive annual competency training. The ADM stated she was responsible to make sure the
DSD was providing the annual nursing competencies.
During a review of the facility document titled, Administrator undated, indicated, The Administrator oversees
the day to day operations of the facility to meet State and Federal regulations and supervise all department
managers to ensure the facility is in compliance. The Administrator is responsible for the delivery of clinical
service . meeting or exceeding quality . Ensures the highest quality in Standards of Care and services
provided . Conducts continuing education programs and special in-service training to all departments'
managers and special in-service for all staff .
3. During an interview on 11/10/21 at 2:08 p.m., with the IP, the IP stated she does not have an IP
certification and was in the process of getting certified. The IP stated the ADM was aware she does not
have an IP certification.
During an interview on 11/10/21, at 4:43 p.m., with the ADM, the ADM stated she was aware the IP was not
certified. The ADM stated she told the IP to complete her IP certification a week upon hire,
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055047
If continuation sheet
Page 39 of 48
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055047
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center
1010 Ventura Avenue
Chowchilla, CA 93610
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0835
but it was not done.
Level of Harm - Minimal harm
or potential for actual harm
During a review of the facility document titled, Infection Control Preventionist-LVN undated, the Infection
Control Preventionist-LVN indicated, .Position Job Description. Responsible for assuming the responsibility
for the Infection Control Program of the facility in accordance with the accepted standards of practice, state
and federal regulations and licensing requirements . Qualifications . Certified in Infection Control .
Residents Affected - Many
4. During a concurrent interview and record review, on 11/10/21, 10:16 a.m., with the DSD, The DSD
reviewed LVN 6's mandatory in-service training. The DSD stated LVN 6 did not have mandatory in-service
training for Abuse Prevention and HIPPA for the year 2020 and 2021. The DSD stated she was not aware
why LVN 6 did not receive the mandatory in-service training. The DSD stated LVN 6 should have receive
the Abuse Prevention and HIPPA mandatory in-service training. The DSD reviewed Certified Nursing
Assistant (CNA) 1's mandatory in-service training. The DSD stated CNA 1 did not receive mandatory
in-service training for HIPPA for the year 2020 and 2021. The DSD stated CNA 1 should have receive the
mandatory in-service training. The DSD stated the mandatory in-service for Abuse Prevention and HIPPA
should have been done yearly. The DSD stated she was responsible to ensure all staff completes the
mandatory in-service trainings.
During a review of the facility document titled, Staff Development Coordinator JOB DESCRIPTION
undated, the Staff Development Coordinator JOB DESCRIPTION indicated, Responsible for planning,
implementing and maintaining of professional development in the clinical department in accordance with
current Federal, State and company standards, guidelines, and regulations. Demonstrates and teaches
resident care in classroom and clinical units to nursing staff . Assess the training of nursing staff to develop,
implement, evaluate and document staff development programs including General orientation, Job specific
Orientation, In-Service, and continuing Education Programs for nursing department personnel .
During an interview on 11/10/21 at 4:43 p.m., with the Admistartor (ADM), the ADM stated staff annual
mandatory training and nursing competencies was not discussed during QAPI. The ADM stated nursing
staff should receive annual competency training. The ADM stated she was responsible to make sure the
DSD was providing the annual nursing competencies.
During a review of the facility document titled, Administrator undated, indicated, The Administrator oversees
the day to day operations of the facility to meet State and Federal regulations and supervise all department
managers to ensure the facility is in compliance. The Administrator is responsible for the delivery of clinical
service . meeting or exceeding quality . Ensures the highest quality in Standards of Care and services
provided . Conducts continuing education programs and special in-service training to all departments'
managers and special in-service for all staff .
5. During a concurrent interview and record on 11/10/21, at 11:32 a.m., with the Director of Staff
Development (DSD), the facility document titled Nursing Staffing Worksheet Patient Per Day (PPD) nursing
hours for 8/21, 9/21, 10/21, and 11/21 was reviewed. The DSD stated staffing had been difficult and the
facility hardly ever met the required nursing hours. The DSD stated, the facility did not have staffing waiver.
The DSD stated, the staffing shortage started with COVID-19 (a contagious serious respiratory infection
transmitted from person to person), the facility just became short staffed and had not been able to build
their team. The DSD stated, the facility had less staffing hours for the resident and that resident's would
occasionally miss showers. The DSD stated, the facility staffed 2 LVNs on am, pm and noc (night) shifts.
The DSD stated, the facility was not using a registry
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055047
If continuation sheet
Page 40 of 48
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055047
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center
1010 Ventura Avenue
Chowchilla, CA 93610
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0835
agency. The DSD stated, the facility had to do something because it was hard on the staff and hard on the
residents.
Level of Harm - Minimal harm
or potential for actual harm
For 8/21 the facility had not met the minimum required nursing contact hours on 11 of 31 days.
Residents Affected - Many
For 9/21 the facility had not met the minimum required nursing contact hours on 21 of 30 days.
For 10/21 the facility had not met the minimum required nursing contact hours on 25 of 31 days
For 11/21 the facility had not met the minimum required nursing contact hours on 10 of 10 days
During an interview on 11/10/21, at 4:43 p.m., with the Administrator (ADM), the ADM stated, it was hard to
retain staff.
During an interview on 11/10/21, at 4:49 p.m., with the ADM, the ADM stated, staffing was discussed at
QAPI (Quality Assurance & Performance Improvement) meeting in September and there were no notes on
discussion of ideas to improve the facility's staffing. The ADM stated, the facility needed 6 CNA's to be fully
staffed and staffing needed improvement.
During a review of the facility policy titled Staffing dated 10/2017, indicated .Our facility provides sufficient
numbers of staff with the skills and competency necessary to provide care and services for all residents in
accordance with the resident care plans and the facility assessment .Staffing numbers and the skill
requirement of direct care staff are determined by the needs of the residents based on each resident's plan
of care .Inquiries or concerns relative to our facility's staffing should be directed to the Administrator or
his/her designee .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055047
If continuation sheet
Page 41 of 48
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055047
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center
1010 Ventura Avenue
Chowchilla, CA 93610
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, the facility failed to maintain an effective infection
control program when:
Residents Affected - Many
1.One of three sampled residents (Resident 27's) gastrostomy tube (a tube inserted through the wall of the
abdomen directly into the stomach. The tube allows patients to receive nutrition directly through stomach)
gravity bag (gravity feeding is a way to deliver feeding formula through the feeding tube. With this feeding
method, formula flows out of a bag and into the tube by gravity) lid was left open when the feeding formula
was being administered.
This failure had the potential to result in Cross contamination for Resident 27.
2. Certified Nursing Assistant did not disinfect the mechanical lift (used to move patients who are unable to
stand on their own or whose weight makes it unsafe to move or lift them manually) in between used for
Resident 3, Resident 41 and Resident 20.
These failures placed Resident 3, 41 and 20 at risk for cross contamination.
3. The facility lobby door was left unlocked, with access to anyone to enter the facility without getting
screened for Corona Virus (COVID-19- a contagious serious respiratory infection transmitted from person
to person) and COVID-19 symptoms.
This failure had the potential to place all residents and staff at increased risk of transmission of COVID-19
infection.
4. One of three sampled residents (Resident 32's) urinary catheter (a tube placed in the body to drain and
collect urine from the bladder) bag was touching the ground.
This failure had the potential for cross contamination.
Findings:
1. During an observation on 11/2/21, at 11:45 a.m., in Resident 27's room, Resident 27 was laying in bed
with the head of bed elevated. Resident 27's gastrostomy-tube feeding was administered with the use of a
gravity feeding bag. Resident 27's gravity feeding bag lid was left open.
During a concurrent observation and interview, on 11/2/21, at 3:57 a.m., with License Vocational Nurse
(LVN) 6. LVN 6 verified the gravity feeding bag lid was open while Resident 27 was receiving the feeding
formula. LVN 6 stated the gravity feeding bag lid should remain close to prevent cross contamination.
During a review of Resident 27's admission Record dated 12/18/14, the admission Record indicated
Resident 27 had a diagnoses of Huntington's disease (is a genetic disorder. It affects the brain that can
lead to problems with moving, memory loss as well as thinking skills) and Dysphagia (difficulty swallowing).
During an observation on 11/3/21 at 8:35 a.m., in Resident 27's room, Resident 27 was laying in bed with
the head of bed elevated. Resident 27's gastrostomy-tube feeding was being administered with
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055047
If continuation sheet
Page 42 of 48
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055047
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center
1010 Ventura Avenue
Chowchilla, CA 93610
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
the use of a gravity feeding bag. Resident 27's gravity feeding bag lid was left open.
Level of Harm - Minimal harm
or potential for actual harm
During a concurrent observation and interview, on 11/3/21, at 10:28 a.m., with LVN 7. LVN 7 verified the
gravity feeding bag lid was open while Resident 27 was receiving the feeding formula. LVN 7 stated the
gravity feeding bag lid should remain close to prevent contaminants causing infections from entering the
gravity feeding bag, mixing with the feeding formula, and directly flow to Resident 27's stomach.
Residents Affected - Many
During an interview on 11/09/21 4:26 p.m., with the Director of Nursing (DON), the DON stated the gravity
feeding bag lid should be closed to prevent cross contaminations.
The facility did not provide the policy and procedure for G Tube feeding.
During a review of the facility document titled, Licensed Practical/Vocational Nurse JOB DESCRIPTION
undated, indicated, Principal Responsibilities . Demonstrates knowledge and appropriate use of the
Company Infection Control Manual . Special Nursing Care Responsibilities . Demonstrates knowledge and
ability to work with: Tube feeding hanging and labeling .
During a review of the professional reference titled Tube Feeding: How to Gravity Feed, retrieved from
http://www.shieldhealthcare.com/community/nutrition/2015/10/23/tube-feeding-how-to-gravity-feed-2/ dated
10/23/15, indicated, .regular gastrostomy tube, flush your tube with water to prime the tubing. Remove the
plunger from the syringe, attach the syringe to your feeding tube, pour 10-15 milliliters of water into the
syringe and let it flow through your tube. Clean off the outside of your formula container with a clean towel
and open it. Closed the clamp on the gravity feeding bag. Open the bag and pour in the desired amount of
feeding formula. Carefully squeeze the air out of the bag and close it .
2. During an observation on 11/3/21, at 8:40 a.m., in the hallway, Central Supply Staff (CSS) brought the
mechanical lift out from Resident 3's room, and Certified Nursing Assistant (CNA) 4 took the lift from CSS,
did not disinfect the lift and placed the lift outside of Resident 41's room.
During an observation on 11/3/21, at 8:56 a.m., in the hallway, CNA 4 took the mechanical lift placed
outside of Resident 41's room, did not disinfect the lift and together with CNA 1 used the lift to weigh
Resident 41. CNA 4 after weighing Resident 41, placed the lift in the hallway without disinfecting the lift.
During an observation on 11/3/21, at 9:34 a.m., in the hallway, CNA 1 took the mechanical lift, did not
disinfect the lift and together with CNA 4 used the lift to transfer Resident 20 from bed to her wheelchair.
During an interview on 11/3/21, at 9:54 a.m., with CNA 1, CNA 1 stated the mechanical lift should have
been disinfected in between residents used to prevent cross contamination. CNA 1 stated the lift should
have been disinfected in between used for Resident 3, Resident 41 and Resident 20.
During an interview on 11/3/21, at 9:57 a.m., with CNA 4, CNA 4 stated the mechanical lift should be
disinfected in between residents used to prevent cross contamination. CNA 4 stated nursing staff touched
the lift during care and residents sometimes would hold on to the lift during care. CNA 4 stated the lift
should have been disinfected in between used for Resident 3, Resident 41 and Resident 20.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055047
If continuation sheet
Page 43 of 48
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055047
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center
1010 Ventura Avenue
Chowchilla, CA 93610
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
During an interview on 11/3/21, at 10:56 a.m., with the CCS, the CCS stated she was helping transfer
Resident 3 using the mechanical lift. The CCS stated she did not disinfect the lift after use to Resident 3,
and should have disinfected the lift to prevent cross contamination.
During an interview on 11/09/21, at 4:26 p.m., with the Director of Nursing (DON), the DON stated the
mechanical lift should have been disinfected between used for Resident 3, 41, and 20. The DON stated the
facility did not have a policy and procedure on disinfecting the mechanical lift in between residents use.
During a review of the professional reference titled Patient Lifts Safety Guide, undated, retrieved from
https://www.fda.gov/files/medical%20devices/published/Patient-Lifts-Safety-Guide.pdf, the Patient Lifts
Safety Guide, indicated, .Patient lift care . Always clean lift before and after each patient use, disinfect all lift
surfaces, Wipe off traces of disinfectant .
3. During an observation on 11/9/21, at 9:41 a.m., in the front lobby, the front lobby door was left unlocked
and accessible to anyone entering the building. The lobby had two offices with no staff present and the
screening station located across the lobby on the east side of the building and was left unattended.
During an interview on 11/9/21, at 10:31 a.m., with Hospitality Aid/Screener (HASR), HASR stated, her
duties included screening, stocking items, and answering call lights to assist resident such as providing
water. HASR stated, she would step away from the screening station at times to perform other duties and
would be alerted when someone needed to be screened because the east hallway entrance was locked
and had a bell. HASR stated, the main lobby door was unlocked, and she was unaware of the reason it was
unlocked. HASR stated, if business office staff were not in their office and when she was performing other
tasks she would not know if someone entered the facility without getting screened. HASR stated, the lobby
area was used at times by family for resident visitation and that the lobby door was left unlocked by the
business office personnel. HASR stated, the purpose of screening was to keep everyone safe and prevent
COVID-19 from entering the facility.
During an interview on 11/9/21, at 10:42 a.m., with Infection Preventionist (IP), IP stated, the purpose of
screening everyone entering the facility was to prevent the possibility of COVID-19 transmission. IP stated,
there was a potential for someone to enter the facility through the lobby door without getting screened.
During an interview on 11/9/21, at 10:49 a.m., with Administrator (ADM), ADM stated the lobby door
remains unlocked when the business office personnel are at the facility. ADM Stated, there is a potential
that someone could enter through the front lobby door without getting screened.
During a review of the facility Mitigation Plan titled Coronavirus Disease 2019 (COVID-19) Mitigation Plan
for skilled Nursing Facilities undated indicated, .The facility screens and documents every individual
entering the facility for COVID-19 symptoms .
During a review of the professional reference retrieved from
https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html titled, Interim
Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus
Disease 2019 (COVID-19) Pandemic dated 11/10/2021 indicated, . 1. Recommended routine infection
prevention and control (IPC) practices during the COVID-19 pandemic Establish a Process to Identify and
Manage Individuals with Suspected or Confirmed SARS-CoV-2 Infection . Establish a process to identify
anyone entering the facility,
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055047
If continuation sheet
Page 44 of 48
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055047
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center
1010 Ventura Avenue
Chowchilla, CA 93610
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Level of Harm - Minimal harm
or potential for actual harm
regardless of their vaccination status, who has any of the following so that they can be properly managed:
1) a positive viral test for SARS-CoV-2, 2) symptoms of COVID-19, or 3) who meets criteria for quarantine
or exclusion from work. Options could include (but are not limited to): individual screening on arrival at the
facility; or implementing an electronic monitoring system in which individuals can self-report any of the
above before entering the facility .
Residents Affected - Many
4. During a concurrent observation and interview on 11/2/21 at 2:26 p.m., with Resident 32, in Resident
32's room, Resident 32 was laying in bed with the catheter bag touching the ground. Resident 32 stated,
after lunch the Certified Nursing Assistant (CNA) emptied his catheter bag.
During a concurrent observation and interview on 11/2/21, at 2:35 p.m., with CNA 6, in Resident 32's room,
Resident 32's catheter bag was touching the ground. CNA 6 stated, the catheter bag should not be on the
ground because there was a risk for infection and cross contamination.
During a review of Resident 32's Care Plan, dated 11/2/21, the Care plan indicted, .Alteration in elimination
of bowel and bladder .Keep drainage bag of catheter below the level of the bladder at all times and off floor
.
During concurrent interview and record review on 11/3/21, at 3:46 p.m., with the DON, the facility policy and
procedure titled Catheter-Care of dated 6/2020 indicted, .Take care to ensure the collection bag does not
touch the floor at any time . The DON stated, the catheter bag should not touch the ground at any time
because it was an infection control issue.
During a review of the professional reference titled, GUIDELINE FOR PREVENTION OF
CATHETER-ASSOCIATED URINARY TRACT INFECTIONS 2009 dated 6/19, from
https://www.cdc.gov/infectioncontrol/guidelines/cauti/ indicate, . Proper Techniques for Urinary Care
Maintenance . Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the
floor . Empty the collecting bag regularly using a separate, clean collecting container for each patient .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055047
If continuation sheet
Page 45 of 48
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055047
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center
1010 Ventura Avenue
Chowchilla, CA 93610
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0882
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Designate a qualified infection preventionist to be responsible for the infection prevent and control program
in the nursing home.
Based on interview, and record review, the facility failed to ensure the designated Infection Preventionist
(IP-professional who ensures healthcare workers and patients are doing all the things they should to
prevent infections) completed the specialized training for IP certification program in accordance with the
facility's policy and procedure and CMS (Centers for Medicare and Medicaid Services) guidelines.
This failure resulted in the IP not meeting the qualifications that would ensure residents were provided with
quality care to prevent or minimize the transmission or spread of COVID-19 (a contagious serious
respiratory infection transmitted from person to person) and/or other infections to all residents and staff.
Findings:
During an interview on 11/10/21 at 2:08 p.m., with the Infection Preventionist (IP), the IP stated she does
not have an IP certification and was in the process of getting certified. The IP stated the Administrator
(ADM) was aware she does not have an IP certification.
During an interview on 11/10/21, at 4:43 p.m., with the ADM, the ADM stated she was aware the IP was not
certified. The ADM stated she told the IP to complete her IP certification a week upon hire, but it was not
done.
During a review of the facility document titled, Infection Control Preventionist-LVN undated, the Infection
Control Preventionist-LVN indicated, .Position Job Description. Responsible for assuming the responsibility
for the Infection Control Program of the facility in accordance with the accepted standards of practice, state
and federal regulations and licensing requirements . Qualifications . Certified in Infection Control .
During a Professional Reference review retrieved on 8/21/2020 from https://www.cms.gov, titled,
Specialized Infection Prevention and Control Training for Nursing Home Staff dated 3/11/19, indicated, .
Specialized Training for Infection Prevention and Control . CMS and the CDC collaborated on the
development of a free online training course in infection prevention and control for nursing home staff. The
course includes information about the core activities of an infection prevention and control program, with a
detailed explanation of recommended practices to prevent pathogen transmission and reduce health-care
associated infections and antibiotic resistance in nursing homes . Completion of this course will provide
specialized training in infection prevention and control . The content of the training covers the following
topics . Infection and Prevention Control Program Overview . Infection Preventionist responsibilities .
Infection Surveillance . Outbreaks . Principles of Standard Precautions . Principles of Transmission-Based
Precautions . Hand Hygiene . Respiratory Hygiene and Cough Etiquette .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055047
If continuation sheet
Page 46 of 48
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055047
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center
1010 Ventura Avenue
Chowchilla, CA 93610
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0921
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and
the public.
Based on observation, interview, and record review, the facility failed to ensure emergency exit routes must
be clear and unblocked to allow quick and safe exit for facility residents, staff and visitors in case of an
emergency when mechanical lifts, wheelchairs, shower beds where stored in front of the emergency exit
doors in the hallway.
This failure had the potential to create delay, panic, and confusion to residents, staff, and visitors in case of
an emergency.
Findings:
During an observation on 11/3/21, at 8:55 a.m., in the hallway the mechanical lift was stored in front of the
emergency exit door.
During a concurrent observation and interview, on 11/3/21, at 9 a.m., with the Director of Maintenance
(DOM) in the hallway, the DOM verified the mechanical lift was stored in front of the emergency door and
was blocking the emergency exit door. The DOM stated the emergency exit door should be unblocked.
During a concurrent observation and interview, on 11/3/21, at 3:02 p.m., with License Vocational Nurse
(LVN) 4 in the hallway, LVN 4 verified one shower chair, two wheelchair, and one mechanical lift was
blocking the emergency exit door. LVN 4 stated the emergency exits door should be unblocked to allow
quick access in the event there is a fire.
During a concurrent observation and interview, on 11/3/21, at 3:09 p.m., with the Administrator (ADM) in
the hallway, the ADM verified the facility equipment was blocking the emergency exit door. The ADM stated
the emergency exit door should be unblocked.
During a review of the facility policy and procedure (P&P) titled, Operational Manual-Physical Environment
dated 8/2020, the P&P indicated, .To ensure sufficient and accessible exits to all for rapid, safe, and orderly
evacuation of the facility. The facility has designated exits for each area of the building to enable rapid
evacuation. Exits are to be kept clear of obstructions that block the entire exit . Facility staff is responsible
for ensuring exits are cleared .If a Facility Staff member discovers a blocked exit, he or she will clear it . and
will report the finding to his or her immediate supervisor .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055047
If continuation sheet
Page 47 of 48
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055047
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center
1010 Ventura Avenue
Chowchilla, CA 93610
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0943
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to
report abuse, neglect, and exploitation.
Based on interview and record review, the facility failed to maintain an effective abuse training program for
one of three employees (Licensed Vocational Nurse (LVN) 6) when employee training was not tracked, and
employee did not complete the mandatory training necessary to identify and report abuse to meet the
needs of the residents.
This failure placed residents at risk for abuse, neglect, and exploitation.
Findings:
During a concurrent interview and record on 11/10/21, at 10:16 a.m., with Director of Staff Development
(DSD), DSD reviewed LVN 6's employee file and training binder. DSD validated that LVN 6 had not
completed abuse training in 2020 and 2021. DSD stated, the abuse training was not done, the abuse
training was supposed to be for all the staff every year. DSD stated, she was responsible for ensuring staff
complete the mandatory training and was her expectation that all staff complete mandatory training. DSD
stated, all staff in-service training had been a problem at the facility for the past year.
During an interview on 11/10/21, at 4:43 p.m., with the Administrator (ADM), ADM stated, the last time the
facility had a Quality Assurance and performance (QAPI) meeting was in September and staff
competencies and training was not discussed. The ADM stated it was the DSD's responsibility to ensure
staff competencies were done yearly. The ADM stated, the DSD needed to develop a tracking system to
ensure all staff trainings were completed.
During a review of the facility's policy and procedure titled, Abuse Prevention and Prohibition Program
dated 8/2020, the policy indicated, .To ensure the Facility establishes, operationalizes, and maintains an
Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and
to ensure a standardized methodology for prevention, identification , investigation, and reporting abuse,
neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state
requirements .All employees, contractors and volunteers will be trained through orientation and ongoing
training sessions, no less than annually, on the following topics .Abuse prevention .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055047
If continuation sheet
Page 48 of 48
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Back to topCitations
33 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0321GeneralS&S Epotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0341GeneralS&S Dpotential for harm
Install a fire alarm system that can be heard throughout the facility.
- 0353GeneralS&S Dpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0355GeneralS&S Epotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
- 0363GeneralS&S Epotential for harm
Install corridor and hallway doors that block smoke.
F711 - Physician Visits
Provide a written emergency evacuation plan.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
F923 - Have adequate outside ventilation by means of windows, or mechanical
Have proper medical gas storage and administration areas.
- 0500GeneralS&S Dpotential for harm
Meet other general requirements that are deficient.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
- 0006GeneralS&S Dpotential for harm
Conduct risk assessment and an All-Hazards approach.
- 0030GeneralS&S Dpotential for harm
List the names and contact information of those in the facility.
- 0037GeneralS&S Dpotential for harm
Establish staff and initial training requirements.
F583 - Privacy and Confidentiality
Keep residents' personal and medical records private and confidential.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F658 - Comprehensive Care Plans
Ensure services provided by the nursing facility meet professional standards of quality.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F693 - Assisted nutrition and hydration
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
F700 - Bed Rails
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
F725 - Nursing Services
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
F726 - Nursing Services
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F802 - Staffing
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F813 - Food Safety Requirements
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
F835 - Administration
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F882 - Infection preventionist
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
F921 - Other Environmental Conditions
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
F943 - Abuse, neglect, and exploitation
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
- 0232GeneralS&S Dpotential for harm
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
FAQ · About this visit
Common questions about this visit
What happened during the November 10, 2021 survey of PALMS CARE CENTER?
This was a inspection survey of PALMS CARE CENTER on November 10, 2021. The surveyor cited 33 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at PALMS CARE CENTER on November 10, 2021?
Yes, 33 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguish..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.