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Palm Terrace Healthcare & Rehabilitation Center : citations
 

about citations

Under state law, a California nursing home can receive a citation and fine for certain violations of the law. Most nursing homes do not receive citations. In a typical year, less than 40% of California's nursing homes receive citations.

Citations are only issued for serious violations. You should be concerned if a nursing home is issued multiple citations in a brief period of time. However, it is also important to look at the nature of the citation. Some citations may indicate facility-wide problems or demonstrate failures to meet a particular care need.

Citations, while serious, should also be put into perspective. A single citation does not necessarily mean that a nursing home will provide poor care. Review the facility's deficiencies and complaints, as well as enforcement actions to see if there is a pattern of violations or if the facility has a fairly good record.

A change of ownership or management can quickly change the quality of care in a facility. Look to see which citations, if any, were acquired under the current owner.

The description for each citation lists the date that it was issued, the class of the citation, the CANHR category, the DPH category, and the amount of the fine. This information is followed by a brief summary of the citation prepared by CANHR.

At the end of each citation description is a citation number. If you want a copy of the actual citation, you will need to request it by citation number. Copies of citations can be obtained at the DPH District Office in the district where the facility is located. (link to DPH L&C district offices)


Includes Citations received by CANHR as of 7/8/2015

summary of citations by year

Citations

2011 
2012 
2013 
2014 
2015 
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description of each citation
details
date
class
canhr category type
DHS category
fine
11/10/2011  Patient Care  Patient Care 

  $10,000.00

 

Name at time: Palm Terrace Healthcare & Rehabilitation Center
On 9/27/11, a male resident wearing a halo brace to prevent undesired motion in his neck banged his head several times against his bed rails and became combative. The Nurse Record showed he had padded side rails, but he did not. The resident could not be managed by the skilled nursing staff and so he was sent back to the emergency room and required additional surgery. These facility failures presented either imminent danger of death or serious physical harm. Citation # 060008726.

04/27/2009  Mandated Reporting  Patient Care 

  $1,000.00

 

Name at time: Palm Terrace Healthcare & Rehabilitation Center
The facility failed to follow its own Policy and Procedures for reporting allegations of abuse. A student nurse observed interactions between a CNA and a resident, where the CNA was shoving food into the resident's mouth, calling her "ugly", and deliberately spilling oatmeal on the resident's face and sweater on 1/17/09. This was reported to the RN supervisor. In an interview with the administrator, the CNA denied allegations of abuse. Records showed the CNA's "voluntary resignation" on 1/29/09. The facility did not suspend the CNA immediately after allegations of abuse were made, therefore the CNA continued to care for the resident after the alleged incident. This was not according to the facility's Policy and Procedures. Citation # 060006121.

01/06/2009  Fall  Patient Care 

  $1,000.00

 

Name at time: Palm Terrace Healthcare & Rehabilitation Center
On 10/8/08, a resident, who was assessed at risk for falls and needing extensive assistance for transfers to and from her wheelchair, fell and fractured her hip. At the emergency room, it was noted the resident had extensive bruising on her upper torso. The facility was cited for failing to implement a careplan that addressed the resident's risk for falls. Citation # 060005755.

12/22/2008  Patient Care  Patient Care 

  $20,000.00

 

Name at time: Palm Terrace Healthcare & Rehabilitation Center
At 11:55 am on 7/30/08, it was noted that a resident's respiration rate was elevated above the normal level and that her abdomen was distended. There was a period of nearly three hours where the resident's vital signs were not documented and the physician was not fully informed of the resident's condition. At 3:50 pm, the staff documented the resident was unresponsive and CPR was started. The resident was pronounced dead at 4:31. The facility was cited for failing to conduct a comprehensive assessment after the resident experienced this change in conditions. Citation # 060005715.

09/11/2008  Physical Restraints  Patient Care 

  $5,000.00

 

Name at time: Palm Terrace Healthcare & Rehabilitation Center
The facility was cited when a resident was found unresponsive on 9/16/07. The residentÌs buttock was on the floor and her head was resting on the mattress. According to staff the residentÌs soft belt restraints were improperly placed, and the resident fell over the side rail while she was unattended. The belt was found still tied to the bed frame, around the back of the residentÌs neck and around her arms. Citation # 060005386.

02/01/2008  AA  Neglect Medication Feeding Supervision  Patient Care 

  $75,000.00

 

Name at time: Palm Terrace Healthcare & Rehab Center
On 3/17/07, a resident, who suffered from dementia, choked on a piece of meat when the facility left her to eat alone in her room without any supervision, despite the fact she was observed to be tired and lethargic. She was hospitalized and died three days later due to airway obstruction. The hospital discovered that, prior to choking, she had overdosed on morphine, even though her physician had not prescribed this medication. The coroner found very high levels of morphine in her blood and concluded that morphine had been administered over a period of time prior to the choking incident. The coroner stated that "there appears to be a high index of suspicion that the morphine played a significant role in the aspiration event." A homicide division detective reported that his office had not been able to determine who administered the morphine to the resident. Citation # 060004611.

10/28/2003  Fall Neglect  Patient Care 

  $60,000.00

 

Name at time: Manor Care Health Services
A 54 year old resident was admitted to the facility on 5/29/03 following a stroke and brain dysfunction due to lack of oxygen. On the same day, he fell while getting out of bed alone and hit his head. The licensed nurse failed to perform continuing neuro assessments, as the facility's policy directed. On 6/2/03, the resident became lethargic and unresponsive and was transferred to the hospital. He was diagnosed with a subdural hematoma, and underwent emergency brain surgery, but remained comatose and died on 6/22/03. Citation # 060001154.

10/08/2003  Decubiti (Bedsores)  Patient Care 

  $1,000.00

 

Name at time: Manor Care Health Services
A resident was identified to be at risk for skin breakdown upon admission on 9/12/00. The facility failed to develop a careplan within seven days to address the resident's risk for skin breakdown. Fourteen days following admission, the resident was diagnosed with a Stage IV bedsore on his left heel. As a result, the resident underwent six months of wound debridement, antibiotic therapy and prolonged bed rest. The facility was cited for failure to address the resident's care needs by developing a careplan and continued assessment of skin integrity. Citation # 060001151.

01/13/2003  Patient Care Infection  Patient Care 

  $3,000.00

 

Name at time: Manor Care Health Services
The resident's physician ordered that her catheter be flushed daily to prevent infection. From 12/9/02 to 12/14/02, the facility did not check the catheter site. On 12/14/02, the resident developed a fever of 104.1 degrees, but the facility did not implement cooling measures. The resident was admitted to the acute hospital for fever and catheter infection. The facility was cited for failure to follow physician's orders, to follow its own catheter policy, and for failure to implement cooling measures upon development of fever. Citation # 060001124.

12/19/2002  Injury  Patient Care 

  $1,000.00

 

Name at time: Manor Care Health Services
The facility gave a glass of extremely hot milk to a 91 year old resident on 6/27/01. No one provided assistance to the resident in handling the hot beverage. She spilled the drink on herself, causing burns that blistered. The attending physician and resident's family were not notified of the incident for almost eight hours. Citation # 060001122.

08/29/2002  Medication  Patient Care 

  $3,000.00

 

Name at time: Manor Care Health Services
On 3/29/02 a resident was admitted with orders for percocet, and morphine for severe pain. It was 16 hours before the resident received any pain medication despite several requests for it. Although, on 3/30/02, the Physical and Occupational Therapist documented the resident's pain level as severe, she was never given morphine, as ordered by her physician. When the resident was discharged on 4/3/02, the pain medication was not sent home with her. The facility failed to identify the pain management needs and failed to administer medication as prescribed. Citation # 060001111.

08/29/2002  Hydr/Nutr  Patient Care 

  $1,000.00

 

Name at time: Manor Care Health Services
On 5/6/02, facility readmitted a 94 year old resident who was totally dependent on staff for all activities of daily living, and received her nutrition and hydration through a gastronomy tube. The facility was cited for failure to identify and implement the care needs of a resident, based on a continuing assessment of her hydration needs. This failure resulted in the resident being admitted to an acute care hospital with severe dehydration and severe urinary tract infection. Citation # 060001112.

01/11/2002  B*  Careplan Hydr/Nutr  Patient Care 

  $15,000.00

 

Name at time: Manor Care Health Services
A resident admitted to the facility on 7/3/01 was assessed to be at high risk nutritionally. Records indicate that from 7/5/01-7/10/01, she lost 10 pounds and that her average daily meal intake began to decline. On 7/29/01, the resident was found unresponsive when paramedics arrived and was transferred to the hospital. The resident's blood volume was severely low and she was semicomatose. The facility failed to identify the resident's care needs, to develop and implement a care plan and to provide necessary fluids for hydration. Citation # 060001081.

01/11/2002  Patient Care Careplan  Patient Care 

  $3,000.00

 

Name at time: Manor Care Health Services
After admission to the facility on 11/8/01, during one week, a resident's ileostomy bag leaked five times. Notes indicated that the ileostomy bag was changed only twice. The lack of care resulted in red and raw skin around stoma. The facility failed to fully assess the resident, to establish care plans, to prevent skin breakdown and to obtain the resident's weight upon admission. Citation # 060001084.

10/25/2001  Medication  Patient Care 

  $1,000.00

 

Name at time: Manor Care Health Services
Following hip surgery in June 2001 a resident was admitted to the facility for physical therapy and pain management. The resident screamed in pain during therapy and transfers from July 6th through July 25th. The staff never performed a pain assessment. As a result the resident became progressively agitated. Finally, orders for morphine were obtained and administered. The facility failed to identify the resident's care needs based on continued assessment. Citation # 060001074.

08/27/2001  Fall  Patient Care 

  $1,000.00

 

Name at time: Manor Care Health Services
The facility was cited for failure to identify and continually assess the care needs of a resident documented as being at risk for falls. On 5/30/01 the resident suddenly stood up from his wheel chair, lost his balance and fell to the floor sustaining a head laceration requiring over forty stitches. Citation # 060001070.

04/24/1998  Patient Care  Patient Care 

  $1,000.00

 

Name at time: MANOR CARE HEALTH SERVICES
Resident first complained of pain on his left leg and hip on 2/29/98 at about 4:15pm and periodically until 2/3/98 -- Resident's physician was not notified until 20 hours after the resident first complained of pain -- Resident was later transferred to an acute care hospital and an X-ray revealed that resident had a fractured left hip -- Facility cited for failing to failing to ensure that resident receive prompt medical attention. Citation # 060000933.

09/05/1997  Decubiti (Bedsores)  Patient Care 

  $1,000.00

 

Name at time: Palm Terrace Healthcare Center
Totally dependent resident at risk for skin breakdown developed pressure sores but careplan was not developed in a timely manner and one sore went to Stage III and became bloody and infected -- facility failed to continuously assess and monitor resident's pressure sores and to ensure that timely and ongoing treatment was provided to heal the sores and prevent infection Citation # 060000823.

12/23/1996  Hydr/Nutr  Patient Care 

  $10,000.00

 

Name at time: Palm Terrace Healthcare Center
36 year old resident transferred to acute care hospital with dehydration and decreased level of consciousness after facility failed to monitor fluid input and output as well as his oral and intravenous therapy Citation # 060000792.

 

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