Palmer Healthcare Center

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.