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Inspection visit

Inspection

PALM CITY NURSING & REHAB CENTERCMS #10583110 citations on this visit
10 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 10 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to develop and implement care plans related resident's noncompliance with fluid restrictions and failed to develop and implement care plans to encourage staff and resident to adhere to fluid restrictions for 1 of 5 sampled residents reviewed for Nutrition / Hydration, Resident #10. The findings included: Record review revealed Resident #10 was admitted to the facility on [DATE] and admitted to Hospice on 06/18/24. Review of the resident's most recent complete assessment, a Significant change Minimum Data Set (MDS), dated [DATE], revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. Resident #10's diagnoses )DX) at the time of the assessment included: Coronary Artery Disease, Heart Failure, Hypertension, Hypernatremia, Hyperlipidemia, Arthritis, Osteoporosis, Cardiac Murmur, Muscle weakness, Need for assistance with personal care, Difficulty in walking, Symbolic dysfunctions, Personal history of Transient Ischemic Attack (TIA) and Cerebral Infarction, Encounter for palliative care. Review of Resident #10's orders included: Fluid Restriction: 1000ml - every shift for NURSING - Day: 120ml; Evening: 120ml; Night: 60ml; DIETARY Breakfast: 360ml; Lunch:180ml; Dinner: 160ml - 06/01/24 with a start date of 06/02/24. On 07/16/24 at 8:14 AM, Resident #10 was observed in bed sleeping with assorted fluids, including bottled beverages and two 16-ounce foam cups of water on the overbed table, dresser and an additional table to resident's right side of bed. During an interview, on 07/16/24 at 1:55 PM, with the Registered Dietitian (RD/LD), when asked about the fluid restrictions, the RD/LD replied, she was not seen by me, she was seen by the previous dietitian, that restriction would come from cardiology or nephrology. On 07/17/24 at approximately 8:30 AM, Resident #10 was observed in bed with a 16-ounce foam cup for hydration on the overbed table, and additional fluids throughout the room. Resident #10 refused to be interviewed. During an interview, on 07/17/24 at 10:33 AM, with the Director of Nursing (DON) and the Staff Development Coordinator, when asked about the fluids and cups of water in the resident's room while the resident had ordered fluid restrictions, the DON stated that she needed to be in contact with the (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 22 Event ID: 105831 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 105831 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm City Nursing & Rehab Center 2505 SW Martin Hwy Palm City, FL 34990 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few physician that ordered the restrictions. The DON further stated, She is on Hospice, and she is very noncompliant, she is even refusing her meds and stuff. Her daughter brings that stuff (referring to bottles of soda and beverages). I talked to the hospice nurse today and told her that she was noncompliant, she said that she would reach out to the doctor about the fluid restrictions. During an interview, on 07/17/24 at 12:05 PM with the Nurse Practitioner (NP), when asked about the fluid restrictions for Resident #10, the NP replied, Hospice was supposed to have discontinued the fluid restrictions. She was on Lasix in the hospital and is not compliant with her medications. On 07/18/24 at 7:31 AM, Resident #10 was observed in bed awake, responsive and declined to be interviewed. During an interview, on 07/18/24 at 9:21 AM, with Staff A, Licensed Practical Nurse (LPN), when asked about providing hydration to the residents, Staff A replied, all staff do hydration, the CNAs [Certified Nursing Assistnats] are responsible for passing hydration at the beginning of the shift. She is no longer on restrictions (confirmed as of 07/17/24). During an interview, on 07/18/24 at 9:31 AM, with Staff D, CNA, when asked about Resident #10 having orders for fluid restrictions, Staff D stated that she was not aware of the restrictions and was providing hydration during the week. On 07/18/24 11:11 AM, the DON stated the facility did not have a policy to address fluid restrictions, we go by what the doctor's order is. Further review of Resident #10's health records revealed there was no care plan to address the resident's fluid restrictions and no care plan to address the resident and family being noncompliant with the fluid restrictions, while the resident's care plan for Nutrition/hydration contradicted the resident's fluid restrictions. Resident #10's care plan for nutrition and hydration, initiated on 09/15/22, documented, Resident is at risk for decreased nutritional status & dehydration r/t [related to] recent hospitalization for non pressure chronic ulcer to LLE [left lower extremity] with cellulitis / MRSA [Methicillin Resistant Staph Aures], TIA, Anemia, Osteoporosis BMI [Basil Mertabolic Index] <23 06/19/24 admitted on Hospice services DX: Cerebral Atherosclerosis. Interventions to the care plan included: o Encourage PO [oral] fluids Date Initiated: 09/15/2022 Created on: 09/15/2022 Created by: name (RN) o Observe for s/s [signs and symptoms] dehydration: i.e. poor skin turgor, dry mucous membranes, labs, concentrated urine, elevated temps and sudden changes in cognition and behaviors Date Initiated: 09/15/2022 Created on: 09/15/2022. During an interview, on 07/18/24 at 9:21 AM, with Staff A, LPN, when asked about Resident #10's fluid restrictions, Staff A replied, her daughter and granddaughter are always here. All staff do hydration, the CNAs are responsible for passing hydration at the beginning of the shift. She is no longer on restrictions. Fluid restrictions were confirmed, by record review, to be discontinued on 07/17/24 after surveyor intervention. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105831 If continuation sheet Page 2 of 22 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 105831 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm City Nursing & Rehab Center 2505 SW Martin Hwy Palm City, FL 34990 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview, on 07/18/24 at 9:44 AM, with Staff B, MDS Coordinator, when asked about Resident #10's care plan, Staff B replied, when I do the admission assessment it triggers the interim care plans (baseline care plans) and then we develop them and personalize the care plan from there. The MDS Coordinator acknowledged the lack of a care plan for the resident and family's noncompliance. When asked about the care plan for nutrition / hydration contradicting the fluid restrictions, the Staff B replied, I took out the Encourage the PO fluid intake yesterday. During an interview, on 07/18/24 at 11:11 AM, the Director Of Nursing stated the facility did not have a policy to address fluid restrictions, we go by what the doctor's order is. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105831 If continuation sheet Page 3 of 22 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 105831 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm City Nursing & Rehab Center 2505 SW Martin Hwy Palm City, FL 34990 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to follow physicians' orders by not administering medications timely for 3 of 3 sampled residents reviewed for residents who received Parkinson's medications, affecting Residents #21, #25, and #310. Residents Affected - Few The findings included: Review of the facility's procedural guidelines, titled, Medication Pass and Med Pass with Medication Cart, with an updated date of 06/28/23, included, in part, the following: Purpose: To assure the most complete and accurate implementation of physician's orders and to optimize drug therapy for each resident by providing for administration of drugs in an accurate, safe, timely, and sanitary manner. Guidance Steps in the Procedure: 7. Administer medications within 60 minutes of the scheduled time. Unless otherwise specified by the physician, routine medications are administered according to the established medication administration schedule for the center. For example, if the medication is ordered for 8:00 AM, it must be given between 7:00 AM and 9:00 AM in order to be considered timely. 1. Record review for Resident #310 revealed the resident was admitted to the facility on [DATE] and discharged from the facility on 05/17/24. Resident #310's diagnoses included Parkinson's Disease Without Dyskinesia Without Mention of Fluctuations, Hereditary and Idiopathic Neuropathy, Muscle Weakness, Unspecified Lack of Coordination Review of the Minimum Data Set (MDS) for Resident #310 dated 05/17/24 documented in Section C a Brief Interview of Mental Status (BIMS) score of 13, indicating an intact cognitive response. Revie of the Physician's Orders for Resident #310 revealed an order dated 05/01/24 for Entacapone Oral Tablet 200 MG Give 1 tablet by mouth five times a day for Parkinson's give with carbidopa-levodopa. Review of the Physician's Orders for Resident #310 revealed an order dated 05/01/24 Ropinirole HCl Oral Tablet 1 MG Give 1 tablet by mouth three times a day for Parkinson's Review of the Physician's Orders for Resident #310 revealed an order dated 05/01/24 for Sinemet Oral Tablet 25-100 MG (Carbidopa-Levodopa) Give 1 tablet by mouth five times a day for Parkinson's give with Entacapone. Review of the time stamp administration of Entacapone, Sinemet (Carbidopa-Levodopa) and Ropinirole from 05/02/24 to 05/08/24 for Resident #310 revealed the following: For the medication Entacapone: 05/02/24 scheduled 8:00 AM given at 9:06 AM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105831 If continuation sheet Page 4 of 22 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 105831 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm City Nursing & Rehab Center 2505 SW Martin Hwy Palm City, FL 34990 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 0684 05/02/24 scheduled 4:00 PM given 5:24 PM Level of Harm - Minimal harm or potential for actual harm 05/03/24 scheduled 8:00 AM given 9:05 AM 05/03/24 scheduled 12:00 PM given 1:01 PM Residents Affected - Few 05/04/24 scheduled 4:00 PM given 6:08 PM 05/06/24 scheduled 8:00 AM given 9:08 AM 05/06/24 scheduled 4:00 PM given at 6:08 PM 05/07/24 scheduled 4:00 PM given 5:45 PM 5/08/24 scheduled 4:00 PM given 7:02 PM. For the medication Sinemet (Carbidopa-Levodopa): 05/02/24 scheduled 8:00 AM given at 9:06 AM 05/02/24 scheduled 4:00 PM given 5:24 PM 05/03/24 scheduled 8:00 AM given 9:05 AM 05/03/24 scheduled 12:00 PM given 1:01 PM 05/4/24 scheduled 4:00 PM given 6:08 PM 05/06/24 scheduled 8:00 AM given 9:08 AM 05/06/24 scheduled 4:00 PM given at 6:08 PM 05/07/24 scheduled 4:00 PM given 5:46 PM 5/08/24 scheduled 4:00 PM given 7:02 PM. For the medication Ropinirole: 05/02/24 scheduled 2:00 PM given 3:05 PM 05/03/24 scheduled 6:00 PM given 7:34 PM 05/08/24 scheduled 6:00 PM given 8:09 PM. In summary, the documentation indicated the medication was not given timely (more than 1 hour before or 1 hour after scheduled time) on several occasions and as late as 2 hours and 2 minutes. During a telephone interview conducted on 07/15/24 at 11:05 AM with the spouse of Resident #310 who was asked about the resident's Parkinson's medications, the spouse stated the resident was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105831 If continuation sheet Page 5 of 22 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 105831 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm City Nursing & Rehab Center 2505 SW Martin Hwy Palm City, FL 34990 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few prescribed a medication for restless leg syndrome with his Parkinson's medications and it affected the resident in a negative way. When asked to explain what this meant, the spouse stated they (facility) had to cut back on the Carbidopa Levodopa because he was having peak doses episode of dyskinesia with limbs flailing all over the place and the mobility was not what it was before being admitted to the facility. When asked about the medications being administered in a timely manner, the resident and the spouse stated the medications were often given late. 2. Record review for Resident #21 revealed the resident was admitted to the facility on [DATE] with diagnoses including: Dementia and Parkinsonism. Review of the MDS for Resident #21 dated 05/07/24 documented in section C, a BIMS could not be completed due to the resident is rarely / never understood. Review of the Physician's Orders for Resident #21 revealed an order dated 11/13/23 for Mirapex Tablet 1 MG (Pramipexole Dihydrochloride) give 1 tablet by mouth three times a day for Parkinson's Review of the Physician's Orders for Resident #21 revealed an order dated 11/13/23 for Carbidopa-Levodopa Tablet 25-100 MG give 1 tablet by mouth three times a day for Parkinson's Disease. Review of the time stamp administration of Carbidopa-levodopa and Mirapex for Resident #21 revealed the following: For the medication Carbidopa-Levodopa: 07/01/24 scheduled for 7:00 AM given 8:39 AM 07/02/24 scheduled 4:00 PM given 5:17 PM 07/03/24 scheduled 4:00 PM given 5:24 PM 07/05/24 scheduled 4:00 PM given 5:09 PM 07/06/24 scheduled 4:00PM given 6:34 PM 07/10/24 scheduled 4:00 PM given 5:49 PM 07/11/24 scheduled 4:00 PM given 7:42 PM 07/12/24 scheduled 11:00 AM given 1:48 PM 07/15/24 scheduled 11:00 AM given 1:21 PM. For the medication Mirapex: 07/05/24 scheduled 2:00 PM given 3:07 PM 07/13/24 scheduled Upon R (6:00 AM -10:00 AM) given 11:11 AM 07/15/24 scheduled Upon R (6:00 AM -10:00 AM) given at 1:23 PM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105831 If continuation sheet Page 6 of 22 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 105831 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm City Nursing & Rehab Center 2505 SW Martin Hwy Palm City, FL 34990 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In summary, the documentation indicated the medication was not given timely (more than 1 hour before or 1 hour after scheduled time) on several occasions and as late as 1 hour and 34 minutes. 3. Record review for Resident #25 revealed the resident was originally admitted to the facility on [DATE] with most recent readmission date of 04/09/24. The resident's diagnoses included: Dementia and Parkinsonism Review of the MDS for Resident #25 dated 07/11/24 documented in Section C, a BIMS score of 6 indicating severe cognitive impairment Review of the Physician's Orders for Resident #25 revealed an order dated 04/09/24 for Carbidopa-Levodopa Oral Tablet 25-100 MG (Carbidopa-Levodopa) give 1 tablet by mouth every 6 hours for Parkinsons. Review of the time stamp for Ropinirole and Carbidopa-Levodopa for Resident #25 revealed the following: For the medication Carbidopa-Levodopa: 07/02/24 scheduled 6:00 PM given 7:55 PM 07/04/24 scheduled 12:00 AM given 1:03 AM 07/04/24 scheduled 12:00 PM given 1:36 PM 07/05/24 scheduled 12:00 PM given 2:38 PM 07/06/24 scheduled 6:00 PM given 7:12 PM 07/07/24 scheduled 12:00 PM given at 1:06 PM 07/09/24 scheduled 12:00 AM given at 1:17 AM 07/09/24 scheduled 12:00 PM given 1:49 PM 07/09/24 scheduled 6:00 PM given 7:17 PM 07/10/24 scheduled 12:00 AM given 1:04 AM 07/10/24 scheduled 12:00 PM given 1:01 PM 07/10/24 scheduled 6:00 PM given 7:25 PM 07/11/24 scheduled 12:00 PM given 1:03 PM. In summary, the documentation indicated the medication (med) was not given timely (more than 1 hour before or 1 hour after scheduled time) on several occasions and as late as 1 hour and 38 minutes. During an interview conducted on 07/17/24 at 9:15 AM with Staff J, Licensed Practical Nurse (LPN), (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105831 If continuation sheet Page 7 of 22 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 105831 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm City Nursing & Rehab Center 2505 SW Martin Hwy Palm City, FL 34990 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Staff J stated she has worked at the facility for 2 months. When asked about med administration times, she said some meds have a specific time to be given and we have a 1 hour window prior and 1 hour window after to give the medication. She said some meds have an upon time and that has a bigger window to give the med but still have 1 hour prior and 1 hour after to give the medication. If for some reason a medication was given late, she said she would notify the doctor and document a reason why it was not given in a progress note. During an interview conducted on 07/17/24 at 9:45 AM with Staff L, LPN, was asked about med administration times. The LPN said we have 1 hour before and 1 hour after the medication is scheduled to give the medication. When asked if a medication is given late what she does, she said she would document why the medication was given late. During an interview conducted on 07/18/24 at 12:20 PM with the Director of Nursing (DON), the DON was asked if she would consider a medication given outside of the 1 hour before or 1 hour after a scheduled time or time frame (prior or upon), the DON said she could not say. When asked if it would be considered 'following the physicians' orders', she said it may be considered not following the doctors' orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105831 If continuation sheet Page 8 of 22 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 105831 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm City Nursing & Rehab Center 2505 SW Martin Hwy Palm City, FL 34990 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 observations, interviews and record review, the facility failed to ensure ongoing care to prevent infection prevention for 1 of 1 sampled resident reviewed for indwelling urinary catheter (Foley) care as evidenced by lack of documentation (Resident #90). The findings included: Review of the facility's policy, titled, Catheter Care and Services, with a revised date of 06/2024 included, in part, the following: A resident with or without an indwelling catheter, receives the appropriate care and services to prevent urinary tract infections to the extent possible. Under Section titled Documentation: Assessments/evaluations, care plans, orders and or nursing measures as appropriate. Record review for Resident #90 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Unspecified Dementia and Neuromuscular Dysfunction of Bladder. Review of the Minimum Data Set (MDS) for Resident #90 dated 06/18/24 documented in Section C a Brief Interview of Mental Status (BIMS) score of 4 indicating severe cognitive impairment. In Section H under Indwelling catheter (including suprapubic catheter and nephrostomy tube) is answered 'yes'. Review of the Certified Nursing Assistant (CNA) Tasks for Resident #90 from 07/08/24 to 07/17/24 revealed no documentation to indicate indwelling urinary catheter care was provided. Review of the Care Plan for Resident #90 dated 06/07/24 with a focus on the resident has Indwelling Catheter r/t [related to] Neurogenic bladder and is at risk for complications. The goal for the Resident to have decreased risk of s/s [signs and symptoms] of a UTI [Urinary Tract Infection] & [and] other complications r/t catheter through review date. The interventions included: Catheter care with warm water & soap. Review of the Physician's Orders for Resident #90 revealed an order dated 06/06/24 for Diagnosis for Indwelling Catheter: neurogenic bladder. Review of the current Physician's Orders for Resident #90 revealed no orders for indwelling urinary catheter (Foley) care. On 07/17/24 at 2:01 PM, an observation of indwelling urinary (Foley) catheter care provided to Resident #90 performed by Staff H, Certified Nursing Assistant (CNA), and assisted by the Registered Nurse Staff Development Coordinator was with no concerns. During an interview conducted on 07/17/24 at 9:15 AM with Staff J, Licensed Practical Nurse (LPN), the LPN stated she has worked at the facility for 2 months. When asked how often Foley care is provided, she said it is provided daily by the CNAs. When asked where they document the Foley care, she said it would be under tasks and it would pop up under tasks for the CNA to (prompt) them to document. During an interview conducted on 07/17/24 at 3:21 PM with Staff K, Certified Nursing Assistant (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105831 If continuation sheet Page 9 of 22 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 105831 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm City Nursing & Rehab Center 2505 SW Martin Hwy Palm City, FL 34990 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 (CNA), Staff K stated he has worked at the facility for 18 years. When asked where they document Foley care, he said they do not document Foley care, it is in the care plan. When asked if he provides Foley care, he said every day, on every shift. When asked where this is documented, he said it is documented under incontinence care that the resident has a Foley. During an interview conducted on 07/17/25 at 3:33 PM with Staff B, MDS (Minimum Data Set) coordinator, she stated she has worked at the facility for 25 years. When asked where a CNA would document Foley care, she said it would be in the task section. When asked where the Foley care documentation is for Resident #90, she said it is in Tasks under the toileting / brief change. When asked what options the CNA have to document, she said they can document incontinence care provided showing the resident has a Foley (indwelling catheter). When asked where the CNA can document actual Foley care provided, she acknowledged there is no place for the CNA to document Foley care provided. She said it is on the [NAME] under bowel and bladder; it has catheter care with warm water and soap. She stated she enters the intervention on the care plan and attaches it to the CNA [NAME]. During an interview conducted on 07/18/24 at 8:40 AM with Staff I, CNA, she stated she has worked at the facility for 6 months. When asked about providing care for residents with indwelling urinary (Foley) catheter, she said we provide the care at least once a shift and she does it every time the resident goes to the bathroom or is incontinent. When asked where she documents the catheter care, she said there is no option to document the catheter care, there is no option to document. There was no documented evidence Resident #90 was provided Foley care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105831 If continuation sheet Page 10 of 22 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 105831 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm City Nursing & Rehab Center 2505 SW Martin Hwy Palm City, FL 34990 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 0692 Provide enough food/fluids to maintain a resident's health. 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 reviews, the facility failed to monitor weights appropriately and failed to ensure weights are accurate for 2 of 5 sampled residents reviewed for nutrition, Residents #29, and #78; and failed to adhere to fluid restrictions for 1 of 5 sampled residents reviewed for Nutrition, Resident #10. Residents Affected - Few Th findings included: The facility's policy, titled, Weight Measurements, with a reference date of 08/2023, documented, in part, the following: Frequency of Measurements and Calculations: Residents are weighed weekly, monthly, or according to physician orders. Residents should be weighed at the same time of day, in similar clothing and using the same scale. Any significant or progressive loss or gain is noted and reported to the resident's attending physician, family, or responsible party and documented in the medical record. Note all new admits are weighed weekly for 30 days. 1. Record review revealed Resident #29 was admitted to the facility on [DATE]. Review of the resident's most recent complete assessment, a quarterly Minimum Data Set (MDS), dated [DATE], Resident #29 had a Brief Interview for Mental Status (BIMS) score of 05, indicating a severe cognitive impairment. The document revealed: Setup or clean up assistance for dining. The resident's diagnoses (DX) at the time of the assessment included: Anemia, Coronary Artery Disease, Heart Failure, Hypertension, Obstructive Uropathy, Hyperlipidemia, Non-Alzheimer's dementia, Chronic Lung Disease, Presence of cardiac pacemaker, Paroxysmal Atrial Fibrillation, Mood disorder, GERD (Gastroesophageal Reflux Disease), Osteoarthritis, Muscle weakness, Overactive bladder, Lack of coordination, Cognitive communication deficit. The MDS documented that the resident did not have any swallowing disorders and no dental concerns. Review of Resident #29's care plan for nutrition, initiated on 01/17/24 with a revision date of 04/23/24, documented, Resident is at risk for decreased nutritional status and dehydration r/t [related to] chronic kidney disease and atherosclerotic heart disease. The goal of the care plan was documented as, Resident will be free from significant weight changes through the review date. Resident will continue to tolerate diet. Continue plan of care. Date Initiated: 01/17/2024. Revision on: 02/06/2024. Target Date: 07/29/2024. Interventions to the care plan included: o RD/DTR [Registered Dietician / Doctor] to evaluate as needed. Date Initiated: 01/17/2024 o Weights as ordered. Date Initiated: 01/17/2024. Resident #29's physician's orders included: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105831 If continuation sheet Page 11 of 22 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 105831 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm City Nursing & Rehab Center 2505 SW Martin Hwy Palm City, FL 34990 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 0692 Regular diet, Regular texture - 01/23/24 Level of Harm - Minimal harm or potential for actual harm Weights every 30 days - 07/07/24. Residents Affected - Few Further review of the resident's electronic health record (EHR) revealed that there were no orders for nutritional supplements. Resident #29's weights taken in the facility were documented as the following: 07/11/24 - 137 lbs (pounds), sit down scale. 07/07/24 - 139 lbs, sit down scale. 04/19/24 - 235 lbs, with wheelchair. 04/12/24 - 165 lbs, sit down scale. 04/03/24 - 165 lbs, sit down scale. 03/02/24 - 172 lbs, sit down scale. 01/17/24 - 187 lbs, sit down scale. Resident #29's weight according to a hospital transfer form (3008) documented a weight of 198 lbs. on 01/17/24. A Nutrition Risk Screen, dated 01/23/24 documented Resident #29's weight as 187 lbs. A Physician / Practitioner Progress note, dated 05/02/24, documented a weight of 187 lbs. A Physician Consult note, dated 07/02/24 documented that the resident was alert and oriented x 3. A Physician / Practitioner Visit Note, dated 07/03/24, documented a weight of 235 lbs. During review of the resident's documented weights, the following were noted: Resident #29 was not weighed per facility protocol of weekly for the first four weeks after admission of 01/17/24. Resident #29 was not weighed from 01/17/24 to 03/02/24. There was a 70-pound weight gain documented from 04/12/24 to 04/19/24, with no verification (re-weight) done to ensure the weights were accurate. There were no weights documented from 04/19/24 to 07/07/24. There was a 96-pound weight loss documented from 04/19/24 to 07/07/24, with no verification done to ensure the weights were accurate. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105831 If continuation sheet Page 12 of 22 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 105831 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm City Nursing & Rehab Center 2505 SW Martin Hwy Palm City, FL 34990 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 0692 Further review of the resident's record revealed: Level of Harm - Minimal harm or potential for actual harm The documented weight loss was not identified by the facility. There were no interventions implemented to address weight loss. Residents Affected - Few There was no documentation of the resident refusing to be weighed. During an interview, on 07/15/24 at 9:54 AM when Resident #29 was asked of any concerns with weight loss, Resident #29 stated that he had lost 15 pounds and is trying to get the weight back. The resident stated, Breakfast is good. Lunch and dinner, sometimes good sometimes bad, depends on who is in the kitchen. I don't like certain vegetables. You can only get what they have - sometimes they offer substitutions. Resident #29 further stated that he had no diet restrictions. The resident stated, There isn't usually anything else that I can get for a meal. When asked about being assessed by the Dietitian, Resident #29 replied, I don't know the Dietitian, I haven't seen one. My daughter brings me things that I like. During an interview on 07/17/24 at 12:10 PM, with the Nurse Practitioner (NP), when asked about the resident voicing concerns about the 15-pound weight loss, the NP replied, the daughter refused any type of stimulant after we found a weight loss. The weights that I use are from the documentation in the record. 2. Record review revealed Resident #78 was admitted to the facility on [DATE]. Review of the resident's most recent assessment, a Quarterly MDS dated [DATE], Resident #78 had a BIMS score of 14, indicating that the resident was cognitively intact. The MDS documented the resident required setup or clean up assistance for eating. Resident #78's diagnoses at the time of the assessment included: Anemia, CAD, Hypertension, PVD (Peripheral Vascular Disease), Hyperlipidemia, Malnutrition, Depression, Chronic Lung Disease, Acute Metabolic Acidosis, partial Intestinal Blockage. Muscle weakness, Difficulty in walking, Thrombocytosis, Allergic Rhinitis, Interstitial Pulmonary Disease, Intussusception, and Osteoarthritis. The MDS documented that Resident #78 had weight loss and was not on a prescribed weight loss regimen. Resident #78's care plan for nutrition, initiated on 07/20/23 with a revision date of 03/13/24, documented, Resident is at risk for decreased nutritional status & dehydration r/t recent hospitalization for compression fracture of L-4, cancer, COPD, CKD (Chronic Kidney Disease), Depression, and Small Bowel Obstruction. He is currently experiencing a significant weight loss which occurred during hospitalization. The goal of the care plan was documented as, Resident will be free from significant weight changes through the review date. Date Initiated: 07/20/2023 Revision on: 04/18/2024 Target Date: 10/14/2024. Interventions to the care plan included: Weights as ordered Date Initiated: 03/05/24 Created on: 07/20/23. Revision on: 03/05/24. Weights as ordered Date Initiated: 02/25/24 Created on: 02/25/24. Resident #78's diet orders included: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105831 If continuation sheet Page 13 of 22 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 105831 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm City Nursing & Rehab Center 2505 SW Martin Hwy Palm City, FL 34990 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 0692 Regular diet, Regular texture - double portions w-B [with breakfast] - 03/13/24. Level of Harm - Minimal harm or potential for actual harm Fortified Foods with meals - 03/13/24. Nutritional Treat with meals for nutritional support w L/D [with lunch and dinner]- 06/14/24. Residents Affected - Few Further review of the resident's orders revealed no order for monitoring weights. Resident #78's weights were documented as follows: 07/11/24 - 159 pounds 06/11/24 - 164 pounds 03/05/24 - 172 pounds 02/25/24 - 187 pounds 01/15/24 - 179 pounds. During the review of the resident's weights, the following were noted: There were no weights documented between 03/05/24 and 06/11/24 - more than three months. There was no documentation of resident refusing weights. On 01/15/2024, the resident weighed 179 lbs. On 07/11/2024, the resident weighed 159 pounds which is a -11.17 % Loss. The weight loss was not identified by the facility. There were no interventions implemented to address weight loss, except for 03/13/24 and 06/14/24. During an interview, on 07/15/24 at 3:30 PM, with Resident #78, when asked of any concerns with weight loss or gain, Resident #78 replied, I got weighed a couple of weeks ago. I was somewhere around 170 pounds and now I am down in the 150s. 3. During an interview, on 07/16/24 at 2:03 PM with the Registered Dietitian, when asked about assessing a resident for weight loss, the Registered Dietitian replied, we are a contract company, I don't know what happened to the previous dietitian, I never got to meet her, I only am able to follow up with what she has done. When asked about the facility's protocols for monitoring residents' weights, the Registered Dietitian replied, the protocol is when they are first admitted , they are to be weighed, once a week for the first four weeks that they are here. When I am here, I run a weight report from the day that I am there to the previous month. If it is not me, I go back 6 months in my report. Anyone that meets my significant criteria (5%, 7%, 10%) I will follow up with them. We are to do that every month. When the Registered Dietitian was shown the documentation of the residents' weights, the Registered Dietitian acknowledged that the residents should have been reweighed on several occasions and that there should have been some interventions based on the reweights. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105831 If continuation sheet Page 14 of 22 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 105831 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm City Nursing & Rehab Center 2505 SW Martin Hwy Palm City, FL 34990 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview, on 07/17/24 at 10:20 AM, with the Staff Development Coordinator (SDC), when asked of the responsibility for weighing the residents, the SDC replied, all of the CNAs are responsible for weights, we put the numbers on the board and the nurses tell them. If we need re-weights, it is put on the board. There is a paper at the beginning of the month for the list of residents that need to be weighed and re-weighted. If it is out of 2-3 pounds change, then reweights are done. Whatever the weight was, we do a reweight to validate that the weight is correct. We try to make sure that they are weighed by the same method, clothing, time of day. We try to do the re-weight if not the same day, within 24 hours. During an interview, on 07/18/24 at 8:47 AM, with Staff C, CNA, when asked about weighing the residents, Staff C replied, there is a list - once a month we get a list, and we give the weights to the nurse. During an interview, on 07/18/24 at 9:13 AM, with Staff A, LPN, when asked about documenting the weights, Staff A replied, I normally compare to the previous one and we document, if we have to do a re-weight, we tell the dietitian and the Director of Nursing (DON) if they lose weight, we check to make sure it is correct and compare to the previous one. Staff A acknowledged that there were multiple opportunities that Resident #29 should have been re-weighed and there was no documentation for the missing weights. 4. Record review revealed Resident #10 was admitted to the facility on [DATE] and admitted to Hospice on 06/18/24. Review of the resident's most recent complete assessment, a Significant change Minimum Data Set (MDS), dated [DATE], Resident #10 had a Brief Interview for Mental Status score of 13, indicating the resident was 'cognitively intact'. Resident #10's diagnoses at the time of the assessment included: Coronary Artery Disease, Heart Failure, Hypertension, Hypernatremia, Hyperlipidemia, Arthritis, Osteoporosis, Cardiac Murmur Muscle weakness, Need for assistance with personal care, Hereditary and idiopathic neuropathy, Difficulty in walking, Symbolic dysfunctions, Personal history of Transient Ischemic Attack (TIA) and Cerebral Infarction, and Encounter for palliative care. Resident #10's orders included: Fluid Restriction: 1000ml - every shift for NURSING - Day: 120ml; Evening: 120ml; Night: 60ml; DIETARY Breakfast: 360ml; Lunch: 180ml; Dinner: 160ml - 06/01/24 with a start date of 06/02/24. On 07/16/24 at 8:14 AM, Resident #10 was observed in bed sleeping with assorted fluids, including bottled beverages and two 16-ounce foam cups of water on the over bed table, dresser and an additional table to resident's right side of bed. During an interview, on 07/16/24 at 1:55 PM, with the Registered Dietitian (RD/LD), when asked about the fluid restrictions, the RD/LD replied, she was not seen by me, she was seen by the previous dietitian, that restriction would come from cardiology or nephrology. On 07/17/24 at approximately 8:30 AM, Resident #10 was observed in bed with 16-ounce foam cup for hydration on the overbed table, and additional fluids throughout the room. On 07/17/24 at 10:33 AM, an interview with the Director of Nursing (DON) revealed the resident is noncompliant and family bring in bottles of soda and beverages to the resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105831 If continuation sheet Page 15 of 22 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 105831 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm City Nursing & Rehab Center 2505 SW Martin Hwy Palm City, FL 34990 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 07/17/24 at 12:05 PM, an interview with the Nurse Practioner (NP) revealed, Hospice was supposed to have d/c [discontinued] the fluid restrictions. She was on Lasix in the hospital and is not compliant with her medications. Provided documentation of education related to fluid restrictions. During an interview, on 07/18/24 at 9:21 AM, with Staff A, LPN, when asked about providing hydration to the residents, Staff A replied, all staff do hydration, the CNAs are responsible for passing hydration at the beginning of the shift. She [Resident #10] is no longer on restrictions (confirmed as of 07/17/24). During an interview, on 07/18/24 at 9:31 AM, with Staff D, CNA, when asked about Resident #10 having orders for fluid restrictions, Staff D stated that she was not aware of restrictions and was providing hydration during the week. On 07/18/24 11:11 AM, the DON stated the facility did not have a policy to address fluid restrictions, we go by what the doctor's order is. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105831 If continuation sheet Page 16 of 22 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 105831 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm City Nursing & Rehab Center 2505 SW Martin Hwy Palm City, FL 34990 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on record review and interview, the facility failed to ensure narcotic medications removal was documented in the medication administration records (MARs) for 3 of 6 sampled residents reviewed for medications (Residents #88, #10 & #46). The findings included: On 07/18/24 at 11:26 AM, during the medication storage review process six (6) residents were selected for review. Three of those residents had discrepancies in their records. Record review revealed Resident #88 had physician orders of Tramadol 50 mg every 8 hours as needed for pain. The controlled medication utilization record was compared against the July 2024 Medication Administration Records (MARs), revealing there were discrepancies. The controlled medication utilization record showed the Tramadol was removed on 07/01/24 at 11:02 AM, and 07/07/24 at 3 AM but there was no documentation in the MARs to reflect this removal and administration to the resident. Record review revealed Resident #10 had physician order of Lorazepam 0.5 mg every 4 hours as needed for anxiety. The controlled medication utilization record was compared against the July 2024 MARs, and revealed there was a discrepancy. The controlled medication utilization record showed the Lorazepam was removed on 07/13/24 at 6:50 PM, but there was no documentation in the MARs to reflect this removal and administration to the resident. Record review revealed Resident #46 had physician order of Alprazolam 0.25 mg by mouth once a day as needed for anxiety. The controlled medication utilization record was compared against the July 2024 MARs, and revealed there was a discrepancy. The controlled medication utilization record showed the Alprazolam was removed on 07/17/24 at 7:36 PM, but there was no documentation in the MARs to reflect this removal and administration to the resident. On 07/18/24 at 12:01 PM, an interview was held with the Director Of Nursing (DON). She was made aware of the findings related to the lack of documentation for the narcotic removal. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105831 If continuation sheet Page 17 of 22 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 105831 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm City Nursing & Rehab Center 2505 SW Martin Hwy Palm City, FL 34990 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain medication error rate less than 5% for 2 of 32 opportunities identified while observing medication pass affecting Residents #32 and #99. The medication error rate was calculated to be 6.25 % (percent). Residents Affected - Few The findings included: Review of the facility's procedural guidelines, titled, Medication Pass and Med Pass with Medication Cart, with an updated date of 06/28/23, included, in part, the following: Purpose: To assure the most complete and accurate implementation of physician's orders and to optimize drug therapy for each resident by providing for administration of drugs in an accurate, safe, timely, and sanitary manner. Guidance Steps in the Procedure: 7. Administer medications within 60 minutes of the scheduled time. Unless otherwise specified by the physician, routine medications are administered according to the established medication administration schedule for the center. For example, if the medication is ordered for 8:00 AM, it must be given between 7:00 AM and 9:00 AM in order to be considered timely. 1. Record review for Resident #32 revealed the resident was admitted to the facility on [DATE] with diagnoses including: Dementia and Other Seizures. Review of the Physician's order for Resident #32 revealed an order dated 07/03/24 for Depakote Sprinkles Delayed Release [DR] 125mg give 2 caps by mouth three times a day for seizures. On 07/15/24 at 4:30 PM, a medication (med) pass observation was conducted with Staff M, Registered Nurse (RN), who was working on the odd side west unit med cart. The RN proceeded to administer Divalproex (Depakote) DR 125mg 2 caps by mouth to Resident #32. Review of the Medication Administration Record (MAR) documented the resident had received the last dose of Depakote at 2:00 PM on 07/15/24. During an interview conducted on 07/15/24 at 4:35 PM with Staff M, who stated she has worked at the facility since November 2023, when asked about medication administration times, she said she had an hour before and an hour after the medication is scheduled to be given. During an interview conducted on 07/15/24 at 5:35 PM with the Director of Nursing (DON) who was asked about med administration times, what specifically Prior indicated, the DON stated they are more liberal with their medication times and Prior would indicate prior to bedtime. When asked to clarify if there was a time frame associated with the Prior to bedtime, she said it could be from 5:00 PM to 8:00 PM depending on when the resident goes to bed. When asked if they keep a log of when a resident goes to bed, she said no they do not. When brought to her attention, the Person-Centered Medication Administration Schedule indicated prior to bed is 6:00 PM to 10:00 PM. She said let's look at a specific resident. Upon the DON reviewing the medication order for Resident #32 for Divalproex DR (Delayed Release) 125mg under the scheduling details, it listed the 'prior to bedtime frame' as 6:00 PM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105831 If continuation sheet Page 18 of 22 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 105831 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm City Nursing & Rehab Center 2505 SW Martin Hwy Palm City, FL 34990 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 to 10:00 PM. Level of Harm - Minimal harm or potential for actual harm 2. Record review for Resident #99 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Essential (Primary) Hypertension, Peripheral Vascular Disease, and Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris. Residents Affected - Few Review of the Physician's orders for Resident #99 revealed an order dated 05/30/24 for Lisinopril 10mg give 1 tablet by mouth one time a day for hypertension. Review of the Medication Administration Record (MAR) for Resident #99 revealed Staff F, RN, marked 9, indicating other see nurse progress note, on 07/18/24 for the medication Lisinopril. Review of the nurse progress notes for Resident #99 for 07/18/24 revealed no nurse progress note. On 07/18/24 at 8:30 AM, a med pass observation with Staff F, RN, who was working on the odd side west unit med cart. The RN proceeded 'to hold' the medication Lisinopril 10mg for Resident #99 after obtaining a blood pressure of 114/73. There were no blood pressure parameters to hold the medication. During an interview conducted on 07/18/24 at 11:55 AM with Staff F, who was asked if there were any parameters to hold the blood Lisinopril for Resident #99, he said no. When asked why he held the Lisinopril for Resident #99, he stated it was nursing judgement call. During an interview conducted on 07/18/24 at 12:20 PM with the Director of Nursing (DON) who was asked if she would consider a medication given outside of the 1 hour before or 1 hour after a scheduled time or time frame (prior or upon), the DON said she could not say. When asked if it would be considered following the physician's orders, she said it may be considered not following the doctor's orders. When asked about holding a blood pressure medication for a resident without parameters to hold the medication, she said the nurse would need to do an assessment and would need to know the baseline blood pressure. When asked about Resident #99 and holding the blood pressure medication Lisinopril for a blood pressure of 114/73, she said she would call the doctor to see if the blood pressure medication should be held. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105831 If continuation sheet Page 19 of 22 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 105831 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm City Nursing & Rehab Center 2505 SW Martin Hwy Palm City, FL 34990 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to secure medications at the bedside for 2 of 115 residents (Resident #72 & #83); failed to secure medication during medication administration (Resident #102); and failed to secure the medication cart while unattended for 1 of 5 med carts The findings included: Review of the facility's procedural guidelines, titled, Medication Storage Room, with an updated date of 06/28/24, included the following, in part: Under Medication Storage Area: Medication storage areas are secure when not under direct supervision of a nurse. 1. Record review for Resident #72 revealed the resident was admitted originally on 07/03/23 with most recent readmission on [DATE] and diagnoses that included: Type 2 Diabetes Mellitus without Complications, Bilateral Primary Osteoarthritis of Knee, and Spinal Stenosis. Review of the Minimum Data Set (MDS) assessment for Resident #72 dated 06/10/24 revealed in Section C, a Brief Interview of Mental Status (BIMS) score of 14 indicating an intact cognitive response. Record review for Resident #72 revealed no Self-Administration of Medication Evaluation. On 07/15/24 10:20 AM, an observation was made of Resident #72 lying in bed with a box of medications on a table across from the foot of her bed. In the box, there was a bag of Vicks Vapocool cough drops, Opcon-A eye allergy relief drops, and a bottle of Ibuprofen. On 07/16/24 at 9:30 AM, a second observation was made of Resident #72 lying in bed with a box of medications on a table across from the foot of her bed. In the box, there was a bag of Vicks Vapocool cough drops, Opcon-A eye allergy relief drops, and a bottle of Ibuprofen. On 07/17/24 at 9:58 AM, a side by side observation was made with Staff L, Licensed Practical Nurse (LPN), of Resident #72 lying in her bed with a box of medications including Vicks Vapocool cough drops, Opcon-A eye allergy relief drops, and a bottle of Ibuprofen. An interview was conducted on 07/15/24 at 10:20 AM with Resident #72 who was asked about the medications. She said she 'does not use them all of the time, some things she has not used for a year.' Resident #72 said the staff know about the medications and it is all right for her to have them because she does not use them much. An interview was conducted on 07/17/24 at 9:58 AM with Staff L who acknowledged Resident #72 had medications at the bedside and she should not have the meds at the bedside. Staff L said this was a very good observation and thanked the surveyor for bringing it to her attention. She sais she would address this immediately with the unit manager and the resident. 2. Record review for Resident #83 revealed the resident was originally admitted to the facility on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105831 If continuation sheet Page 20 of 22 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 105831 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm City Nursing & Rehab Center 2505 SW Martin Hwy Palm City, FL 34990 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 [DATE] with readmission on [DATE] with diagnoses that included: Unspecified Dementia, Unspecified Symptoms and Signs Involving Cognitive Functions and Awareness, Cognitive Communication Deficit, Gastro-Esophageal Reflux Disease without Esophagitis. Review of the MDS assessment for Resident #83 dated 06/20/24 revealed in Section C, a BIMS score of 6, indicating severe cognitive impairment. Review of the Physician's Orders for Resident #83 revealed an order dated 12/28/23 for a 'Regular diet Regular texture.' On 07/15/24 at 10:30 AM, an observation was made of Resident #83 sleeping in bed with the nightstand top drawer open and inside the drawer were Ricola cough drops. Photographic Evidence Obtained. On 07/16/24 at 9:20 AM, a second observation was made of Resident #83 sitting up in bed eating breakfast with the nightstand top drawer was open and inside were the Ricola cough drops. On 07/17/24 at 9:55 AM, a side by side observation was made with Staff L, LPN, of Resident #83 lying in her bed with the nightstand next to bed and the top drawer was open. Three (3) Ricola cough drops were inside. Staff L immediately removed the cough drops. An interview was conducted on 07/17/24 at 9:56 AM with Staff L who was asked about the cough drops at the bedside for Resident #83. She said this is a problem, the resident should not have these at the bedside, and she is on a soft diet. Staff L acknowledged the resident should not have the cough drops at the bedside, as they are a medication. 3. Record review for Resident #102 revealed the resident was admitted to the facility on [DATE] with diagnoses including: Chronic Obstructive Pulmonary Diseases (COPD), and Chronic Respiratory Failure with Hypoxia. Review of the Physician's orders for Resident #102 revealed an order for Umeclidinium-Vilanterol (Anoro Ellipta) Inhalation Aerosol Powder Breath Activated 62.5-25mcg/ACT 1 puff inhale orally one time a day for COPD. On 07/17/24 at 9:05 AM, during a medication pass observation with Staff J, LPN, for Resident #102 after administering medications including Anoro Ellipta, she left the Anoro Ellipta inhaler on dresser across from the resident (out of the LPN's sight) while she went into the resident's bathroom to throw trash away and wash hands. An interview was conducted on 07/17/24 at 9:15 AM with Staff J who stated she has worked at the facility for 2 months. When asked why she left the inhaler on the dresser out of her sight while washing hands in the resident's bathroom, she said she did not want to bring the medication into the bathroom to cause any kind of cross contamination. When asked could she have put the inhaler on the resident's overbed table and rolled the overbed table to the bathroom doorway so she could keep the inhaler in her sight while washing her hands, she said yes. She acknowledged she should have kept the inhaler in her sight at all times. Staff J stated when asked about residents having medications at the bedside, that residents are not allowed to have medications at the bedside, if she saw medications at the bedside for a resident, she would ask her supervisor what to do, all medications should be locked up. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105831 If continuation sheet Page 21 of 22 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 105831 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm City Nursing & Rehab Center 2505 SW Martin Hwy Palm City, FL 34990 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 FORM CMS-2567 (02/99) Previous Versions Obsolete 4. On 07/17/24 from 8:18 AM to 8:20 AM, an observation was made of the med cart left unlocked and unattended outside of room [ROOM NUMBER]. An interview was conducted on 07/17/24 at 8:22 AM with Staff A, LPN, who stated she has worked at the facility at the facility for 11 months. When asked if the med cart located outside of room [ROOM NUMBER] was assigned to her today, she said yes. When asked about the med cart being unlocked and left unattended, she said she is not supposed to leave the cart unlocked when she is away from the cart. Staff A LPN acknowledged she left the med cart unlocked and unattended. Event ID: Facility ID: 105831 If continuation sheet Page 22 of 22

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Citations

10 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.

  • 0656GeneralS&S Dpotential for harm

    F656 - Comprehensive Care Plans

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  • 0684GeneralS&S Dpotential for harm

    F684 - Quality of care

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  • 0690GeneralS&S Dpotential for harm

    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.

  • 0692GeneralS&S Dpotential for harm

    F692 - Assisted nutrition and hydration

    Provide enough food/fluids to maintain a resident's health.

  • 0755GeneralS&S Dpotential for harm

    F755 - Pharmacy Services

    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  • 0759GeneralS&S Dpotential for harm

    F759 - Medication Errors

    Ensure medication error rates are not 5 percent or greater.

  • 0761GeneralS&S Dpotential for harm

    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.

  • 0004GeneralS&S Dpotential for harm

    Develop and maintain an Emergency Preparedness Program (EP).

  • 0030GeneralS&S Dpotential for harm

    List the names and contact information of those in the facility.

  • 0031GeneralS&S Dpotential for harm

    Provide emergency officials' contact information.

FAQ · About this visit

Common questions about this visit

What happened during the July 18, 2024 survey of PALM CITY NURSING & REHAB CENTER?

This was a inspection survey of PALM CITY NURSING & REHAB CENTER on July 18, 2024. The surveyor cited 10 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at PALM CITY NURSING & REHAB CENTER on July 18, 2024?

Yes, 10 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be ..."

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

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Next steps

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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.