Palmer Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review, the facility failed to ensure that the Resident Representative had the right to make decisions on behalf of the Resident for one Resident (#17) out of a total sample of 15 residents.Specifically, for Resident #17, the facility failed to ensure that the court-appointed Guardian had the legal authority to elect advanced directives (written instructions, such as a medical order form that records a resident's treatment wishes in the event of a medical emergency) on behalf of the Resident when the Guardian signed Resident #17's Massachusetts Medical Orders for Life Sustaining Treatment (MOLST) form. Findings include:Resident #17 was admitted to the facility in [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD), dementia, failure to thrive, and malignant neoplasm of the kidney. Review of the document titled, Decree and Order of Appointment of Guardian for an Incapacitated Person for Resident #17, dated [DATE], indicated but was not limited to the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate and reflective of the resident's status at the time of the assessment, for two Residents (#7 and #5), out of a total sample of 15 residents. Specifically,1. For Resident #7, the facility failed to complete a Patient Health Questionnaire-9 (PHQ-9-an assessment for mood and depressive symptoms) Assessment when the Resident had documented psychological disorders.2. For Resident #5, the facility failed to accurately code that the Resident sustained falls with injury on the MDS Assessments dated 5/29/25 and 11/20/25, when the Resident had documented falls with injury within the assessment periods. Findings include: 1. Resident #7 was admitted to the facility in March 2018 with diagnoses including bipolar disorder with psychotic features, schizoaffective disorder, mood disorder, and psychosis. Review of Resident #7's MDS assessment dated [DATE] indicated: -the Resident was moderately…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had severe cognitive impairment and was dependent on staff to meet his/her healthcare needs, the Facility failed to ensure he/she was treated in a respectful and dignified manner, when after eliciting the attention of Activity Aide #1, Activity Aide #2 used his fingers to jiggle the loose skin under Resident #1's neck while laughing and saying, [NAME], [NAME]. Activity Aide #2 did this in the presence of other residents and staff members.Findings include:Review of the Facility's policy titled, Resident Rights, dated 05/28/21, indicated Federal and state laws guarantee certain basic rights to all residents of this facility, including the right to be treated with respect, kindness, and dignity.Review of the Facility's policy titled, Dignity, dated 05/28/21, indicated the following:-Residents are treated with dignity and respect at all times.-Demeaning practices and standards of care that compromise dignity are…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had severe cognitive impairment and was dependent on staff to meet his/her care needs, the Facility failed to ensure staff implemented and followed their Abuse Policy, when on 11/30/25, Activity Aide (AA) #1 witnessed a potential incident of verbal and physical abuse and did not immediately report the incident as required, therefore placing Resident #1 and other residents at risk for abuse.Findings include:Review of the Facility policy titled Abuse Prevention Program, dated as revised March 2022, indicated that all employees are responsible to immediately report any violation or alleged violations.Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 12/01/25, indicated that on 12/01/25, Activity Aide (AA) #1 reported to the Activity Director that on 11/30/25, she witnessed AA #2 making a comment mimicking a [NAME] sound while touching the loose skin under Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had severe cognitive impairment and was dependent on staff to meet his/her care needs, the Facility failed to ensure staff implemented and followed their Abuse Policy, when 07/01/25, Certified Nurse Aide (CNA) #1 witnessed an incident of verbal abuse and did not report the incident immediately as required, therefore placing Resident #1 and other residents at risk for abuse. Findings include:Review of the Facility policy titled Abuse Prevention Program, dated as revised March 2022, indicated that all employees are responsible to immediately report any violation or alleged violations. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 07/01/25, indicated that on 07/01/25, CNA #1 reported to the Executive Director that she heard CNA #2 (agency CNA) verbally abuse Resident #1 while assisting him/her during lunch. Review of the report indicated the alleged incident had occurred at 12:50 P.M.Review of the Facility Incident Report, dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and policy review, the facility failed to maintain a clean and sanitary environment in the main facility kitchen to prevent contamination and the spread of foodborne illnesses. Specifically, the facility staff failed to ensure that: 1) equipment in the facility kitchen was clean and free of dust and debris. 2) hair restraints were worn to prevent potential physical contamination of food/fluids. 3) the facility dish machine was appropriately tested for temperature and sanitation requirements by Dietary Staff when the minimum sanitation requirements were not met, putting the facility residents at risk for contamination and foodborne illnesses. Findings include: Review of the facility policy titled Kitchen Sanitation, dated 6/15/20, indicated the food service area is maintained in a clean and sanitary manner. The policy included the following: -All kitchen, kitchen areas and dining areas are kept clean, free from garbage and debris . -All utensils, counters, shelves and equipment are kept clean . -All equipment, food contact services and utensils are…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record and policy review, and interview, the facility failed to ensure respect (regard for the feelings, wishes, rights, and traditions of others) and dignity (the state or quality of being honored or respected) for one Resident (#3), out of total sample of 17 residents. Specifically, for Resident #3, the facility had video monitoring in the Resident's bedroom without consent (agreement to do something), with video images of the Resident's body visible on a monitor screen in the Unit nursing station placing Resident #3 at risk for an undignified existence. Findings include: Review of facility policy titled Dignity, dated 5/28/21, indicated: -Each resident shall be cared for in a manner that promotes and enhances his/her sense of wellbeing .and feelings of self-worth and self-esteem. -Residents are treated with dignity and respect at all times. -The facility culture supports dignity and respect .by honoring choices, preferences, values, and beliefs. This begins with admission and continues throughout the residents stay. -Individual needs and preferences .are…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record and policy review, the facility failed to provide reasonable accommodation of resident needs for one Resident (#207), out of a total sample of 17 residents. Specifically, the facility failed to provide Resident #207, who was identified as being at risk for falls, with access to his/her call bell at all times to allow the Resident to call for staff assistance when needed. Findings include: Review of the facility policy titled, Call Bells, dated 5/28/21 indicated the following: -Purpose: to have a communication system to allow residents to call for assistance. -Place call bell/light within reach of resident . Resident #207 was admitted to the facility in September 2024, with diagnoses including Parkinson's Disease (a progressive degenerative disorder of the central nervous system characterized by tremor and impaired muscular coordination), Diabetes Mellitus (DM - disease in which the body's ability to produce or respond to the hormone insulin is impaired resulting in elevated blood glucose [sugar] levels in the blood), and urinary frequency.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record and policy review, the facility failed to provide treatment and care in accordance with professional standards relative to the proper setting of pressure reducing and relieving devices for two Residents (#37and #2) who were at risk of skin breakdown. Specifically, the facility failed to: 1. For Resident's #37, maintain the pressure-reducing air mattress settings as ordered by the Physician. 2. For Resident #2, to ensure the Physician's order for an air mattress was implemented for the Resident who was bed bound, identified as being at increased risk for skin breakdown, and had a history of skin breakdown. Findings include: Review of the facility policy titled Support Surface Guideline, dated 5/28/21, indicated the following: -The purpose of this procedure is to provide guidelines for the assessment of appropriate pressure reducing and relieving devices for residents at risk of skin breakdown. -Redistributing support surfaces prevent skin breakdown, promote circulation and provide pressure relief or reduction. -Support surfaces are modifiable.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record and policy review, the facility failed to provide supervision and an environment free of accident hazards for one Resident (#1), out of a total sample of 17 residents. Specifically, the facility failed to ensure that Resident #1 was provided with supervision, when the Resident who was determined as being at risk for elopement was observed outside of the facility in close proximity of a parking lot without staff supervision. Findings include: Review of the the facility policy titled Wandering and Elopement, dated 6/11/21, indicated: -the facility strives to promote resident safety by maintaining a process to screen all residents for risk of elopement and implement preventative strategies for those identified at risk. The policy also included the following: -If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. Resident #1 was admitted to the facility in March 2018, with diagnoses including Bipolar Disorder with psychotic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record and policy review, the facility failed to provide food that was designed to meet the individual needs of one Resident (#2) out of a total sample of 17 residents. Specifically, the facility failed to ensure that Resident #2 was provided with the Physician's prescribed diet consistency of mechanical soft consistency (altered diet in which foods difficult to chew are chopped, ground, shredded, cooked or altered in some way to make them easier to chew and swallow) when the Resident was offered regular consistency items not allowed on his/her diet and pureed (texture modified diet where foods have been altered so that they have a smooth, cohesive, pudding-like consistency) meal items that was not ordered or the Resident's preference. Findings include: Review of the facility policy titled Therapeutic Diet Orders, dated 6/15/20, indicated it was the policy of the facility to assure that residents receive and consume foods in the appropriate form .as prescribed by the Physician…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record and policy review, the facility failed to ensure that one Resident (#3) out of a total sample of 17 residents was free from accidental risk of injury or entrapment. Specifically, the facility failed to ensure the scoop mattress (a mattress with raised edges on all four sides to prevent accidental rolling out of bed) being used for Resident #3 was compatible with the bed frame when there was a significant gap between the scoop mattress and foot board, placing the Resident at risk for injury or entrapment. Findings include: Review of facility policy titled Bed Safety, dated 5/28/21, indicated: -Our facility shall strive to provide a safe sleeping environment for the resident. -The residents sleeping environment shall be assessed by the interdisciplinary team (IDT), considering resident safety, medical conditions, comfort, freedom of movement, as well as input from the resident's family regarding sleeping habits and bed environment. -The facility shall identify additional…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure the Food Service Director (FSD) held the required qualifications. Specifically, the facility failed to ensure there was a full-time Registered Dietitian (RD) when the FSD: - was not a certified dietary manager. - was not a certified food service manager. - did not have a similar national certification in food service management and safety. - did not have an Associate's degree or higher in food service management or in hospitality. - did not have two or more years of experience in the position of director of food and nutrition services in a nursing facility setting. Findings include: Review of the list of key personnel, provided by the facility, indicated a FSD was in place. During an interview on 8/10/23 at 7:41 A.M., the Regional FSD said he was covering for the facility's FSD because she was on vacation. He said the RD for the facility worked part-time. The Regional FSD provided a certificate held by the FSD. Review of the certificate indicated the FSD completed a course that included the safe handling of food.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review and interview, the facility failed to ensure that it provided discharge planning services with respect for the wishes of one Resident (#11) out of a total sample of 17 residents. Specifically, -For Resident #11, the facility failed to provide referrals and education based on the activated (made active) Health Care Proxy's (HCP-the legal document you use to tell medical providers who should make decisions about your care if you're not competent to do so) expressed desire to transfer the Resident to another skilled nursing facility closer to their home. Findings include: Resident #11 was admitted to the facility in March 2023 with diagnoses including Dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of the facility policy on Discharge Plan, dated 5/8/21, indicated that residents transferring to another skilled nursing facility . will be assisted in selecting a post-acute care provider that is relevant and applicable to the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.