Inspection visit
Inspection
9 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 9 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of policy and procedure, observation, interview and record review, the facility failed to maintain
residents' privacy in a dignified manner for 3 of 24 sampled residents observed, Residents #103, #100, and
#68.
The findings included:
Review of the facility policy and procedure on 08/16/23 at 2:45 PM, titled, Dignity, provided by the Director
of Nursing (DON) revised February 2021, documented in part, Policy Statement: Each resident shall be
cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with
life, and feelings of self-worth and self-esteem. Policy Interpretation and Implementation 1. Residents are
treated with dignity and respect at all times 11. Staff promote, maintain and protect resident privacy,
including bodily privacy .
1. Resident #103 was initially admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with
diagnoses that included Cerebral Infarction, Peripheral Vascular Disease, Diabetes Mellitus Type II,
Hypertension, Muscle Wasting and Atrophy, Major Depressive Disorder and Generalized Anxiety Disorder.
The Minimum Data Set (MDS) assessment documented a Brief Interview Mental Status (BIM) score of 15
or 15 indicating cognition was intact.
On 08/14/23 at 11:20 AM, an observation of Resident # 103, from the main North wing resident's room
hallway (bedroom door ajar), revealed the resident with both the left below-the-knee (BKA) amputation old
incisional site, as well as her uncovered, loosely worn diaper, visibly exposed to other residents, staff
members and visitors, who passed the door, for over an hour. Facility staff members were observed walking
by the room and not closing the curtains or the resident's bedroom door. Upon entering the resident's room,
there was an increased bodily exposure visibility. The two (2) hanging privacy curtains in the room did not
provide a full covering of protection for the resident.
Photographic Evidence Obtained.
During a subsequent observation conducted on 08/14/23 at 2:30 PM, Resident # 103 was again observed
from the main North wing resident room hallway (bedroom door ajar) with both her left BKA amputation old
incisional site, as well as her uncovered, loosely worn, diaper both visibly exposed for a time period of at
least 30 minutes. Facility staff members were observed walking by the room and not closing the curtains or
the resident's bedroom door.
An interview ws conducted with Resident #103 on 08/15/23 at 2:17 PM, who when asked if the staff treat
you with respect and dignity and keep your person covered, at all times, stated, for the most
(continued on next page)
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 13
Event ID:
105336
Printed: 05/28/2026
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
105336
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/17/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center and Rehab
3370 NW 47th Terrace
Lauderdale Lakes, FL 33319
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 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
part they do, but on a few occasions the door and curtain were both left opened and the resident stated that
she had to remind the staff to close it.
An interview was conducted with Staff H, (CNA), on 08/15/23 at 2:18 PM, regarding the resident's privacy
curtains and bedroom door, both being left open, Staff H acknowledged the bedroom door and privacy
curtains should not be left open, exposing the resident.
An interview was conducted with Staff C, Registered Nurse (RN), on 08/15/23 at 2:26 PM, who
acknowledged the resident's bedroom door should not be left open in such a way as to expose the resident
and her diaper at any time.
An interview was conducted with Staff I, North wing RN, Assistant Director of Nursing (RN/ADON), on
08/16/23 at 3:24 PM, who acknowledged the resident's bedroom door should not be left open in such a way
as to expose the resident and her diaper at any time.
There were no documented behaviors relative to this observation, for this resident noted in either her care
plan, or in the progress notes.
The Director Of Nursing (DON) acknowledged that on 08/16/23 at 9:40 AM that the resident's bedroom
door should not be left open in such a way as to expose the resident's person and her diaper at any time.
2. A medication administration observation pass was conducted on 08/15/23 at 8:50 AM with Staff A,
Licensed Practical Nurse (LPN) for Resident #100. Staff A gathered Resident #100's medications entered
Resident #100's room. Staff A entered the resident's bathroom, washed her hands, donned gloves and
prepared to administer Resident #100's medications via the gastric tube in Resident #100's abdomen. Staff
A neglected to close the room door or the privacy curtain for Resident #100's room. Staff A administered
the medications through Resident #100's gastric tube, which left the resident exposed to staff members and
residents walking in the main hallway.
3. A catheter care observation was conducted on 08/17/23 at 7:50 AM with Staff G, Certified Nursing
Assistant (CNA), for Resident #68. At the end of the catheter care, Staff G realized she did not have an
incontinence brief for Resident #68. Staff G stated, I would normally put a 'diaper' on, but I don't have one,
so I will get a new 'diaper' and then come back and put the 'diaper' on her. Resident #68 stated she
preferred to wear an 'incontinence brief'. Staff G again stated, I will get a new 'diaper' and then come back
and put the 'diaper' on her.
The above concerns were reviewed with the Director of Nursing, the Assistant Director of Nursing, and the
Nursing Educator on 08/17/23.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105336
If continuation sheet
Page 2 of 13
Printed: 05/28/2026
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
105336
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/17/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center and Rehab
3370 NW 47th Terrace
Lauderdale Lakes, FL 33319
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 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews, and record review, the facility failed to provide the appropriate Activities of Daily
Living (ADLs), regarding eating assistance, for 1 of 5 sampled residents reviewed for nutrition, Resident
#23.
Residents Affected - Few
The findings included:
Review of the policy, titled, Activities of Daily Living, revised in March 2118, showed, in part, the following:
appropriate care and services would be provided for residents who cannot carry out ADLs [Activities of
Daily Living] independently by the plan of care, including support and assistance with dining. The resident's
response to interventions will be monitored, evaluated, and revised as appropriate.
Record review documented Resident #23 was readmitted to the facility on [DATE] with diagnoses to include
Heart Disease and Dementia. Resident #23 had been placed under hospice services on 05/31/23. The
Minimum Data Set (MDS) assessment dated [DATE] documented Resident #23 had a Brief Interview of
Mental Status (BIMS) score of 00, indicating severe cognition impairment. The MDS, dated [DATE], for
eating under section G, documented Resident #23 required extensive assistance with one person assist.
The MDS dated [DATE], under section G, documented Resident #23 needed supervision and set up only
for eating.
In an observation conducted on 08/14/23 at 12:35 PM, Resident #23 was noted in her room with her lunch
tray. Closer observation showed that no staff were in the room to assist Resident #23 with her lunch meal.
At 12:42 PM, there was no staff noted in her room, and at 12:55 PM, Resident #23's lunch meal was barely
touched.
In an observation conducted on 08/15/23 at 8:40 AM, Resident #23 was in her room with Staff F, Certified
Nursing Assistant (CNA), helping the resident with her breakfast meal. The meal was about 30%
consumed, and at 8:47 AM, Staff F left the room. At 8:50 AM, Resident #23 was trying to eat independently
but stopped and the tray was only 30% consumed. Continued observation showed that at 8:57 AM, the tray
was taken out of her room.
In an observation conducted on 08/15/23 at 1:08 PM, Resident #23 was noted in her room with no
assistance provided from staff. Closer observation showed Resident #23 only ate about 20% of her meal.
Review of the care plan revised on 08/16/23 showed that Resident #23 has a self-care deficit related to
weakness, limited endurance, and terminal diagnoses and hospice care.
Review of the progress note dated 08/02/23 showed that Resident #23 has no family or friends involved in
her care. Another progress note dated 08/03/23 showed that Resident #23 was assisted by staff with ADLs
extensively.
Review of the Nutrition Risk Evaluation dated 08/03/23 showed that Resident #23 was inactive, totally
dependent, and needed extensive or complete assistance while eating.
An interview was conducted on 08/17/23 at 8:38 AM, Staff D, CNA, who stated Resident #23 can eat
independently and usually eats about 50% of her meals.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105336
If continuation sheet
Page 3 of 13
Printed: 05/28/2026
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
105336
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/17/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center and Rehab
3370 NW 47th Terrace
Lauderdale Lakes, FL 33319
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 0677
An interview was conducted on 08/17/23 at 1:00 PM with the Administrator, and she was told of the
findings.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105336
If continuation sheet
Page 4 of 13
Printed: 05/28/2026
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
105336
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/17/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center and Rehab
3370 NW 47th Terrace
Lauderdale Lakes, FL 33319
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.
Based on observations, interviews, policy review, and record review, the facility failed to provide proper
urinary catheter care, as evidenced by cleaning the catheter tubing from the outside to the insertion site,
wiping the buttocks from the top downward into the perinium, lifting the catheter bag above the bladder
level, lack of hand hygiene after touching unclean items, and allowing the catheter tubing to be kinked after
care, for 1 of 1 sampled resident, Resident #68, reviewed for catheter care.
The findings included:
Review of the policy, titled, Catheter Care, Urinary, Level III, dated August 2022, revealed, in part, the
following:
Check the resident to be sure he or she is not lying on the catheter and to keep the catheter and tubing free
of kinks.
Position the drainage bag lower than the bladder at all times to prevent urine from flowing back into the
urinary bladder.
Use a washcloth to cleanse the labia-use one area of the washcloth for each downward, cleansing stroke.
Change the position of the washcloth and cleanse around the urethral meatus. With a clean washcloth,
rinse using the above technique. Use a clean washcloth to cleanse and rinse the catheter from insertion
site to approximately four inches outward.
Check the drainage tubing and bag to ensure the catheter is draining properly.
A urinary catheter care observation was conducted on 08/17/23 at 7:50 AM with Staff G, Certified Nursing
Assistant (CNA) for Resident #68. Staff G began her care on the left side of Resident #68's bed. She
opened Resident #68's incontinence brief, which appeared to be clean. Staff G then removed her gloves
and washed her hands. Staff G completed perineal care on the right and left sides of the perinium. Staff G
then cleaned the catheter tubing from the connection point (outward) toward the insertion site. Staff G
realized she had no washcloths to continue the care, so she covered the resident and left the room to
retrieve washcloths.
Upon returning to the room with the washcloths, Staff G moved to the right side of Resident #68's bed and
while moving the bedside table, the package of perineal care wipes fell onto the floor. The CNA changed
her gloves but did not wash her hands at this time. Staff G stated she was going to lower the head of the
bed so Resident #68 could roll to her left side, but she could not find the bed controller. The surveyor
located the bed controller on the floor under the bed. Staff G then retrieved the remote control, reposited
the head of the bed and asked Resident #68 to roll onto her left side. Wearing the same gloves, Staff G
then prepared a washcloth and wiped Resident #68's bottom from top downward (incorrectly). She
verbalized she would wash her hands at this time but did not wash her hands and changed her gloves.
Staff G removed Resident #68's incontinence brief and the non-disposable incontinence pad, verbalized
she would wash her hands but did not, and changed her gloves. Staff G then wet an additional washcloth
and cleaned the remainder of the urinary catheter tubing and catheter bag. She then lifted the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105336
If continuation sheet
Page 5 of 13
Printed: 05/28/2026
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
105336
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/17/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center and Rehab
3370 NW 47th Terrace
Lauderdale Lakes, FL 33319
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
catheter bag to her (CNA) height and set the catheter bag onto the bed. She verbalized again she would
wash her hands but did not but did change her gloves. She then used a dry washcloth and dried the
catheter tubing and bag and then placed the catheter bag onto the side of the bed. Staff G began to cover
Resident #68, but the surveyor intervened and showed the resident's catheter tubing was kinked. The
surveyor asked Staff G to straighten it.
Residents Affected - Few
The concerns regarding this urinary catheter care were reviewed with the Director of Nursing, Assistant
Director of Nursing, and Nursing Educator on 08/17/23, following the observations.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105336
If continuation sheet
Page 6 of 13
Printed: 05/28/2026
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
105336
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/17/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center and Rehab
3370 NW 47th Terrace
Lauderdale Lakes, FL 33319
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
observations, interviews, and record review, the facility failed to follow the correct tube feeding formulary
and rate as per the physicians' orders for 1 of 2 sampled residents reviewed for tube feeding, Resident
#100.
The findings included:
Review of the facility's policy, titled, Enteral Nutrition, revised in 2018, showed, in part, the following: The
Nurse confirms that orders for enteral nutrition are complete. Complete orders include a. The enteral
nutrition product; b. Delivery site (tip placement); The specific enteral access device (nasogastric, gastric,
jejunostomy tube, etc.; c. d. Administration method (continuous, bolus, intermittent); e. Volume and rate of
administration; f. The volume/rate goals and recommendations for advancement toward these; and g.
Instructions for flushing (solution, volume, frequency, timing, and 24-hour volume).
Resident #100 was admitted on [DATE] and readmission on [DATE] with diagnoses of Hemiplegia and
Muscle Wasting. Review of the physician orders dated 08/10/23 showed an order for Renal Novasource
(tube feeding formulary type) to run at 60 milliliters (ml) an hour for 18 hours at 4:00 PM and off at 10:00
AM.
In an observation conducted on 08/14/23 at 9:50 AM, Resident #100 was noted in the bed with the tube
feeding Jevity 1.5 (tube feeding formulary type and not the ordered Renal Novasource) running at 60
milliliters an hour. The tube feeding Jevity 1.5 at 60 ml an hour provides 1620 calories daily.
In an observation conducted on 08/15/23 at 8:35 AM, Resident #100 was noted in bed with the tube
feeding Jevity 1.5 (tube feeding formulary type and still not the ordered Renal Novasource) running at 60
milliliters an hour.
Review of the Nutrition Risk Evaluation dated 08/10/23 showed that Resident #100 currently receives Jevity
1.5 at 80 milliliters an hour for 18 hours. Resident #100 had a significant weight change due to a week of
hospitalization. The estimated caloric needs showed 1890 to 2240 calories daily needs. The tube feeding
Jevity 1.5 running at 80 ml an hour would have provided 2160 calories daily.
The care plan revised on 07/17/23 showed that Resident #100 is at risk for complications associated with
enteral feeding; and to administer enteral feeding and flushes as ordered with routine registered dietitian
assessment.
An observation conducted on 08/15/23 at 4:00 PM of the facility's supply room showed that they had
stocked three types of tube feeding formula: Jevity, Nepro, and Glucerna. There was no Renal Novasource
and no other types of tube feeding formulas noted.
An interview was conducted on 08/16/23 at 11:00 AM with the Registered Dietitian (RD) who stated any
order for tube feeding formulary that is not in-house, they (the nurses) should contact her (RD) in person or
by phone for an appropriate substitution. She further stated that her phone number was posted in the
nurses' station.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105336
If continuation sheet
Page 7 of 13
Printed: 05/28/2026
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
105336
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/17/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center and Rehab
3370 NW 47th Terrace
Lauderdale Lakes, FL 33319
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
An interview was conducted on 08/17/23 at 8:33 AM, Staff A, Licensed Practical Nurse (LPN), who stated
that if she had an order for tube feeding, she would take the tube feeding bottles from the general supply.
Staff A said they have three types of tube feeding in-house, Jevity, Nepro, and Glucerna. When asked what
she would do if there were any orders for tube feeding, they do not have in-house, she said she would
notify the Director of Nursing (DON). She further said that they did not have orders this year of tube feeding
that they did not have in stock. Staff A reported that if she needed to contact the Registered Dietitian, her
number is posted in the nurse's station.
An interview was conducted on 08/17/23 at 1:00 PM with the Administrator, and she was informed of the
findings.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105336
If continuation sheet
Page 8 of 13
Printed: 05/28/2026
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
105336
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/17/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center and Rehab
3370 NW 47th Terrace
Lauderdale Lakes, FL 33319
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.
4. During an observation conducted on 08/16/23 at 9:45 AM of the Central Supply room, with Staff J,
Central Supply Clerk, and the DON, it was noted that there was a container of Beneprotein powder
supplement with an expiration date of July 2023. Photographic Evidence Obtained.
5. During a observation conducted on 08/16/23 at 10:23 AM, with Staff K, Licensed Practical Nurse (LPN),
and the DON, of the South Medication Room, it was observed that there were two (2) expired boxes of
over-the-counter (OTC) Mineral Oil Enemas, dated 11/21 and 07/22 respectively. Both were located in a
cabinet alongside other active / ready-to-use stock medications.
Photographic Evidence Obtained.
During an interview conducted on 08/16/23 at 10:35 AM with Staff K and the DON, both acknowledged that
the expired protein powder and the OTC Mineral Oil Enemas should all have been promptly discarded.
Based on observations, interviews, and record reviews, the facility failed to maintain medications,
medication carts and treatment carts in a secure manner and during medication administration
opportunities, as evidenced by medications left unattended at the bedside for Resident #100 and 22 and
failed to dispose of expired medications and supplements properly on 1 of 2 units (the North Unit).
The findings included:
Review of the policy, titled, Storage of Medications, dated November 2020, revealed in part, the following:
Drugs and biologicals used in the facility are stored in locked compartments. Only persons authorized to
prepare and administer medications have access.
1. During tour of the facility conducted on 08/14/23 at 9:24 AM, the surveyor observed an unlocked,
unattended treatment cart on the North Hallway of the facility. The treatment cart contained various
treatments and ointments. Photographic Evidence Obtained.
Upon further observation, there were 2 pairs of scissors observed in the top drawer of the wound care cart.
During this observation, multiple staff members were noted in the hallway walking past the treatment cart.
An additional observation was conducted on 08/14/23 at 9:30 that revealed this treatment cart had been
moved from its initial location by the wound care nurse and was in use at a resident's room door.
2. A medication administration observation pass was conducted on 08/15/23 at 8:50 AM with Staff A,
Licensed Practical Nurse (LPN) for Resident #100. While preparing the prescribed medications, Staff A
noted she did not have the correct form (tablets) of the prescribed Vitamin D, but rather only had the
capsule form in the medication cart. Staff A stated she was going to ask another nurse if she had the tablet
form of Vitamin D. Staff A walked to the other end of the hallway, approximately 100 meters away, to talk to
another nurse on duty. She left the medication cart unlocked, with other medications (tablets and liquids)
already poured into medication cups, on top of the medication cart.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105336
If continuation sheet
Page 9 of 13
Printed: 05/28/2026
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
105336
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/17/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center and Rehab
3370 NW 47th Terrace
Lauderdale Lakes, FL 33319
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
Photographic Evidence Obtained.
Level of Harm - Minimal harm
or potential for actual harm
There were multiple staff members in the hallway during this time, distributing and collecting breakfast trays
from residents. During this observation, Staff A was away from the unlocked, unattended medication cart
and medications for approximately 5 minutes.
Residents Affected - Few
The facility's Assistant Director of Nursing was in the hallway as well and observed this unlocked,
unattended medication cart and medications. She intervened and spoke to Staff A who was returning to the
cart.
Upon entering Resident #100's room to administer the medications, Staff A placed the medications on the
bedside table and entered the bathroom to wash her hands. The medications were not within her line of
sight.
3. A medication administration observation was conducted on 08/15/23 at 11:33 AM with Staff C,
Registered Nurse (RN) for Resident #22. Upon entering Resident #22's room to administer the medication,
Staff C placed the medications on the bedside table and entered the bathroom to wash her hands. The
medications were not within her line of sight.
The above concerns were reviewed with the facility's Director of Nursing (DON), Assistant Director of
Nursing (ADON), and Nursing Educator on 08/17/23.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105336
If continuation sheet
Page 10 of 13
Printed: 05/28/2026
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
105336
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/17/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center and Rehab
3370 NW 47th Terrace
Lauderdale Lakes, FL 33319
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 0805
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual
needs.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews, and record review, the facility failed to ensure that the food was prepared and
appropriate to meet the residents' needs of 4 of 6 sampled residents observed during dining observations,
Resident #23, Resident #36, Resident #98, and Resident #83.
The findings included:
Review of the facility policy, titled, Nutrition Service Policy and Procedures, under mechanical soft diet,
dated 07/01/23, showed that this diet consists of moist, smooth textured, and quickly formed into a bolus.
Most raw fruits and vegetables, seeds, nuts, and dried fruits are excluded. It further showed that vegetables
should be soft, well cooked and less than ½ inch in size, and easily mashed with a fork.
Review of the facility's spring-summer menu 2023, week 1, showed the following menus for Monday: under
the regular diet: pork roast, parsley egg noodles, and one piece of parsley sprig. Under the mechanical soft
diet, it showed: grounded pork roast, parsley egg noodles, and one piece of parsley sprig.
1. Resident #23 was readmitted to the facility on [DATE] with diagnoses of Dementia and Anxiety. The diet
order dated 08/03/23 documented a mechanical soft diet.
In an observation conducted on 08/14/23 at 12:35 PM, Resident #23 was noted in her room with her lunch
tray. Closer observation showed a tray of Mechanical soft diet with chopped pork, mashed potatoes, mixed
vegetables, vanilla ice cream, and a piece of raw parsley sprig about 3 inches long.
2. Resident #36 was admitted to the facility on [DATE] with diagnoses of Diabetes and Anemia. The
quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS)
score of 15, indicating cognition was intact. The diet order was noted for no added salt-controlled
carbohydrates mechanical soft texture.
In an observation conducted on 08/15/23 at 8:45 AM, Resident #36 was in the room eating the breakfast
tray. Closer observation showed a tray with chopped breakfast meat and a piece of raw parsley sprig about
3 inches long.
3. Resident #98 was readmitted on [DATE] with diagnoses of Dysphagia and Dementia. The diet order
dated 01/25/23 was noted for mechanical soft diet and small bite-size pieces. The annual MDS showed a
BIMS score of 03, indicating severe cognitive impairment.
In an observation conducted on 08/14/23 at 12:48 PM, Resident #98 was noted with his lunch tray that
consisted of a mechanical soft diet with chopped meat and a piece of raw parsley sprig that was about 3
inches long.
4. Resident #83 was readmitted on [DATE] with diagnoses of Schizophrenia and Dysphagia. The diet order
dated 08/11/23 noted a mechanical soft texture and pureed vegetables. The Quarterly MDS dated [DATE]
showed BIMS of 15, which is cognitively intact.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105336
If continuation sheet
Page 11 of 13
Printed: 05/28/2026
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
105336
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/17/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center and Rehab
3370 NW 47th Terrace
Lauderdale Lakes, FL 33319
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 0805
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
In an observation conducted on 08/15/23 at 8:46 AM, Resident #83 had eaten her food on the breakfast
tray. Closer observation showed a breakfast tray with chopped breakfast meat and a piece of raw parsley
sprig that was about 3 inches long.
An interview was conducted on 08/17/23 at 8:11 AM, with Staff E, Speech Pathologist, who stated they
provide three types of diet consistencies: regular, mechanical soft, and pureed. When asked about a
mechanical soft diet supplied by the facility, she said it is grounded, moist meats and food on the sticky
side. Staff E stated the vegetables need to be small, easily mashed, and not raw vegetables.
An interview was conducted on 08/17/23 at 8:30 AM with the Corporate Dietary Manager who
acknowledged all findings.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105336
If continuation sheet
Page 12 of 13
Printed: 05/28/2026
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
105336
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/17/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palms Care Center and Rehab
3370 NW 47th Terrace
Lauderdale Lakes, FL 33319
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 0808
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or
licensed dietitian, to the extent allowed by State law.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews, and chart review, the facility failed to provide the correct diet orders and nutritional
supplements, and failed to ensure accurate food allergies were followed, for 1 of 5 sampled residents,
Resident #23, reviewed for nutrition.
The findings included:
An observation was conducted on 08/14/23 at 12:35 PM of Resident #23. The resident was observed in her
room with her lunch tray. Closer observation revealed a tray of a mechanical soft diet with vanilla ice cream.
There was no nutritional supplements noted on this lunch tray.
Record review showed that Resident #23 was readmitted to the facility on [DATE] with diagnoses of Heart
Disease and Dementia. Resident #23 was placed under hospice services on 05/31/23. The Minimum Data
Set (MDS) dated [DATE] showed Resident #23 has a Brief Interview of Mental Status (BIMS) score of 00,
indicating severe cognitive impairment.
The care plan revised on 08/03/23 documented that Resident #23 was at nutritional risk and to provide
supplements as ordered and diet as requested.
The paper chart at the nurse's station documented that Resident #23 was allergic to eggs, poultry, milk
products, wheat, and chocolate. Further review showed a yellow communication slip with a cardiac diet
order written on 08/01/23 but was never updated in the electronic system.
The physicians' orders documented the following: Regular diet mechanical soft texture, thin consistency,
dated 08/03/23. From 03/16/23 to 07/31/23, the resident had a written order for health shake (nutritional
supplement) 3 times a day. This order was noted to not be reordered when Resident #23 was readmitted to
the facility on [DATE].
The Nutrition Risk Evaluation dated 08/03/23 documented that Resident #23 was only allergic to eggs. The
Nutrition assessment dated [DATE] documented that Resident #23 has allergies to eggs, chocolate, and
wheat. Further review of the Nutrition Risk Evaluation dated 08/03/23 showed that Resident #23 received a
mighty shake (nutritional supplement) 3 times a week. Review of the Medication Administration / Treatment
Record for August 2023 did not show evidence that a mighty shake was given 3 times a day to Resident
#23.
An interview was conducted on 08/17/23 at 10:00 AM with the Director of Nursing, who stated the yellow
communication slips are sometimes placed in the actual paper chart when residents get readmitted to the
facility at night or after hours. The yellow slip is then filled and given to the kitchen to prepare the
appropriate diet order for the residents. The DON stated the nurse will later place the diet order into the
electronic system. When asked about the discrepancies in allergies that were noted in the different
assessments for Resident #23, she said that she would look into it.
An interview was conducted on 08/17/23 at 1:00 PM with the Administrator, who was informed of the
findings.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105336
If continuation sheet
Page 13 of 13
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
9 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.
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.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
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.
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.
F805 - Food and drink
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
F808 - Therapeutic Diets
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
- 0300GeneralS&S Dpotential for harm
Meet other general requirements that are deficient.
- 0511GeneralS&S Dpotential for harm
Have properly installed electrical wiring and gas equipment.
FAQ · About this visit
Common questions about this visit
What happened during the August 17, 2023 survey of PALMS CARE CENTER AND REHAB?
This was a inspection survey of PALMS CARE CENTER AND REHAB on August 17, 2023. The surveyor cited 9 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at PALMS CARE CENTER AND REHAB on August 17, 2023?
Yes, 9 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriat..."
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.