Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Palmer Healthcare Center during CMS and state inspections, most recent first.
A resident with COPD, dementia, failure to thrive, and kidney cancer was severely cognitively impaired, yet the court-appointed guardian signed the resident’s MOLST even though the guardianship decree did not show authority to elect advanced directives. The MOLST and physician orders listed DNR, DNI, do not use non-invasive ventilation, DNH, and other limits, while the DON stated the resident should have been Full Code because the guardian did not have authority to complete the MOLST.
MDS assessments were inaccurate for two residents. One resident with significant psychiatric diagnoses had a BIMS score showing moderate cognitive impairment, but the PHQ-9 was not completed even though it should have been. Another resident with gait and balance problems had documented falls, including one with a head laceration requiring hospital evaluation and staples, and another fall with injury, but the MDS assessments did not code the falls correctly.
A resident with severe cognitive impairment was subjected to undignified treatment when an activity aide jiggled the resident's neck skin and laughed in front of others. This behavior was witnessed by staff, who intervened and reported the incident. The aide later admitted to the action, which was found to violate facility policies on dignity and respect.
A staff member failed to immediately report a witnessed incident where another staff member engaged in inappropriate physical and verbal behavior toward a resident with severe cognitive impairment. The incident, which included mocking and derogatory language, was not reported until the following day, contrary to facility policy requiring immediate reporting of abuse allegations.
A CNA failed to immediately report a witnessed incident of verbal abuse by another CNA toward a resident with severe cognitive impairment and total care needs. The incident occurred during a meal, where the resident was subjected to a loud, derogatory comment in front of others. The witnessing CNA delayed reporting the event to the Executive Director, contrary to facility policy requiring immediate reporting of abuse allegations.
The facility failed to maintain a clean and sanitary kitchen environment, with issues such as dust-laden equipment, improper use of hair restraints, and inadequate testing of dish machine sanitation levels. Staff were observed not following proper procedures, leading to potential contamination risks.
A resident with severe cognitive impairment and under guardianship was subjected to unauthorized video monitoring in their bedroom, with images displayed at the nursing station. The facility failed to obtain consent, a physician's order, or develop a care plan for the monitoring, violating the resident's dignity and privacy. The DON acknowledged the lack of policy and consent, highlighting a significant oversight in respecting the resident's rights.
A resident at risk for falls, with conditions including Parkinson's Disease and Diabetes Mellitus, was observed without access to a call bell, contrary to the facility's policy and the resident's care plan. The resident, who was cognitively intact and required assistance, was twice found in a wheelchair without the call bell within reach, highlighting a failure to accommodate the resident's needs.
The facility failed to maintain correct air mattress settings for two residents at risk of skin breakdown. One resident's mattress was set to 85 pounds instead of the prescribed 135 pounds, while another's was set to 210 pounds instead of between 120 and 150 pounds. Despite documentation indicating regular checks, staff were unaware of the incorrect settings, leading to discomfort and potential risk for the residents.
A resident with severe cognitive impairment and identified as an elopement risk was observed unsupervised on a patio with an open gate leading to a parking lot and main road. The facility's policy required supervision for such residents, but the practice of scheduled supervised outdoor time had been discontinued. The DON acknowledged the resident's elopement risk and the concern of the open gate, highlighting a deficiency in maintaining a safe environment.
A resident on a mechanically soft diet due to dysphagia was provided with meals that did not meet their dietary needs, including regular consistency and pureed items not ordered or preferred. The resident expressed dissatisfaction with the food, and staff interviews revealed a lack of awareness and education regarding the resident's dietary restrictions. The Food Service Director and Staff Development Coordinator acknowledged discrepancies in meal preparation and staff training.
A resident with severe cognitive impairment was at risk of injury due to a scoop mattress that was incompatible with the bed frame, creating a significant gap at the foot of the bed. The mattress change was made without notifying maintenance staff, and no safety audit was conducted at the time, contrary to the facility's bed safety policy.
Guardian Signed MOLST Without Documented Authority
Penalty
Summary
The facility failed to ensure that the resident representative had the legal authority to make decisions on behalf of a resident when the court-appointed guardian signed the resident’s Massachusetts Medical Orders for Life Sustaining Treatment (MOLST) form. Resident #17 was admitted with diagnoses including COPD, dementia, failure to thrive, and malignant neoplasm of the kidney, and the MDS assessment showed severe cognitive impairment with a BIMS score of 5 out of 15. The court decree appointing the guardian did not indicate authority to elect advanced directives. The resident’s MOLST listed advanced directives of DNR, DNI, do not use non-invasive ventilation, and DNH, and the guardian signed the MOLST. The physician order report also listed advanced directives including DNR, DNI, DNH, no dialysis, no artificial nutrition, no artificial hydration, and guardian in place. During interview, Nurse #1 stated residents with a guardian are Full Code because guardians do not have the authority to complete a MOLST. The DON stated the guardian completed a new MOLST indicating DNR/DNI and said the resident should have been Full Code but was not Full Code.
MDS assessments were inaccurate for mood screening and fall history
Penalty
Summary
The facility failed to ensure MDS assessments were accurate and reflective of resident status for two residents. For one resident with diagnoses including bipolar disorder with psychotic features, schizoaffective disorder, mood disorder, and psychosis, the MDS assessment showed a BIMS score of 11 out of 15, indicating moderate cognitive impairment, but the PHQ-9 was not assessed. The medical record did not show that a PHQ-9 assessment had been attempted during the assessment period. The DON stated the PHQ-9 for that assessment was not completed but should have been, and the SW stated the PHQ-9 is used quarterly to look for changes in mood and that not completing it could affect psychosocial care. For another resident admitted with abnormal gait, weakness, lack of coordination, and unsteadiness on feet, the record documented falls with injury during the assessment periods, but the MDS assessments did not reflect those events. Nursing notes showed the resident was found on the floor with a head laceration and later returned from the hospital with ten staples to the right side of the head, and the fall with laceration was reported to the Department of Public Health. Additional nursing notes documented another fall with a bump to the head and an abrasion to the back, and a separate fall where the resident was found on the floor next to the bed with no injuries. The DON stated the MDS Coordinator and Corporate Consultant reviewed the resident's MDS assessments and that both were coded incorrectly relative to falls.
Resident Not Treated with Dignity by Activity Aide
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and total dependence on staff for care was not treated with dignity and respect by an activity aide. The aide, in the presence of other residents and staff, used his fingers to jiggle the loose skin under the resident's neck while laughing and repeatedly calling the resident's name. This action was witnessed by another activity aide, who immediately told the aide to stop and described the behavior as rude. Additional staff members were aware of the incident, with one hearing the aide make a comment and begin playing with the resident's neck, and another hearing the admonishment that the behavior was not funny. The resident involved had a diagnosis of unspecified dementia with associated anxiety, restlessness, and agitation, and was unable to be interviewed due to severe cognitive impairment. The incident took place in the facility's dining/activity room, where several residents and staff were present. The aide involved later stated that he intended to be playful and did not perceive his actions as inappropriate, but acknowledged tickling the resident's neck skin. The incident was reported to the activity director and subsequently to the DON, who initiated an internal investigation. Facility policies reviewed by surveyors clearly stated that residents are to be treated with dignity and respect at all times, and that demeaning practices are prohibited. The actions of the activity aide were found to be in violation of these policies, as the resident was subjected to undignified treatment in a public setting, witnessed by both staff and other residents.
Failure to Immediately Report Witnessed Abuse Incident
Penalty
Summary
A deficiency occurred when staff failed to immediately report a witnessed incident of potential verbal and physical abuse involving a resident with severe cognitive impairment and total dependence on staff for care. The facility's Abuse Prevention Program policy required all employees to immediately report any violations or alleged violations, but this protocol was not followed. An activity aide observed another aide flicking the loose skin under a resident's chin while mimicking a sound and laughing, as well as calling the resident derogatory names after an incident with a tablet. The aide who witnessed the incident did not report it to the Activity Director until the following day and did not provide full details until later that afternoon. Interviews confirmed that the aide recognized the interaction as inappropriate but did not think to report it immediately, despite facility policy. The delay in reporting was acknowledged by both the Activity Director and the Director of Nursing, who stated that the incident should have been reported right away. The resident involved had a diagnosis of unspecified dementia with anxiety, restlessness, and agitation, and was unable to be interviewed due to severe cognitive impairment. The failure to promptly report the observed abuse placed this resident and potentially others at risk, as required procedures for immediate reporting were not followed.
Failure to Immediately Report Witnessed Verbal Abuse
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) witnessed an incident of verbal abuse directed at a resident with severe cognitive impairment and failed to report the incident immediately, as required by the facility's Abuse Prevention Program policy. The incident took place during lunch, when one CNA overheard another CNA, who was an agency staff member, make a loud, derogatory comment about the resident in the presence of the resident and three others at the dining table. The resident involved had diagnoses including Down Syndrome, unspecified dementia, and seizures, and was dependent on staff for care. Due to the resident's severe cognitive impairment, he or she was unable to respond to questions about the incident. The CNA who witnessed the event did not report the alleged abuse to the Executive Director until one hour and forty-five minutes after the incident, instead proceeding to provide care to another resident. The delay in reporting was acknowledged by the CNA during an interview, stating that the incident should have been reported immediately. Other staff, including a nurse present at the time, were not informed of the incident by the witnessing CNA. The facility's policy requires all employees to immediately report any violations or alleged violations, and this requirement was not followed in this case.
Sanitation and Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in the main kitchen, which is essential to prevent contamination and the spread of foodborne illnesses. During an initial kitchen tour, the surveyor observed dust-laden fans, a dusty shelf under a portable air conditioner, and a dusty utensil rack over the cook's preparation area. Additionally, clear stacked storage containers were found to be wet inside, indicating they were not thoroughly dried, which could lead to mold and bacterial growth. Dietary Aide #4 confirmed that the containers should not have been stacked while wet. The facility also failed to ensure that hair restraints were worn by staff to prevent potential physical contamination of food and fluids. During a follow-up visit, a staff member was observed preparing food without a hair restraint, acknowledging that a hair net should have been worn. The utensil rack remained dusty, indicating ongoing issues with cleanliness and sanitation in the kitchen area. Furthermore, the facility did not appropriately test the dish machine for temperature and sanitation requirements. Dietary Aide #2 was observed running the dish machine without checking the chemical sanitizer levels, which were found to be too high. The aide admitted to not being educated on when to check the sanitizer. Upon further inspection, it was discovered that the test strips used to check the sanitizer were expired, and the dish machine was not meeting the required sanitation standards. The Food Service Director acknowledged these issues and the need for proper checks before using the dish machine.
Unauthorized Video Monitoring of Resident
Penalty
Summary
The facility failed to ensure respect and dignity for a resident by implementing video monitoring in the resident's bedroom without obtaining consent. The resident, who was admitted with a diagnosis of dementia and had severe cognitive impairment, was under guardianship due to incapacity to make personal decisions. The video camera was positioned in the resident's room, capturing images that were displayed on a monitor at the nursing station, exposing the resident's body without consent. The facility's policy on dignity emphasized the importance of respecting residents' private space and property, which was not adhered to in this case. The deficiency was further highlighted by the lack of documentation in the resident's medical record regarding the need for video monitoring, a physician's order, or a comprehensive, person-centered care plan. Interviews with facility staff, including the Director of Nursing, revealed that the video monitoring had been in place for several months without proper assessment, consent from the resident's guardian, or a policy governing its use. The Director of Nursing acknowledged the oversight and confirmed that the facility did not have a policy on video monitoring, and consent was not obtained, which was a concern for the resident's dignity.
Failure to Provide Call Bell Access for Fall-Risk Resident
Penalty
Summary
The facility failed to provide reasonable accommodation for a resident identified as being at risk for falls by not ensuring the resident had access to their call bell at all times. The facility's policy on call bells, dated May 28, 2021, mandates that call bells should be placed within reach of residents to allow them to call for assistance. However, during observations on September 26, 2024, the surveyor noted that the resident's call bell was hanging behind the bed and was not within reach, despite the resident being in a wheelchair and needing assistance to move. The resident, who was admitted with diagnoses including Parkinson's Disease, Diabetes Mellitus, and urinary frequency, was assessed as cognitively intact and at risk for falls. The resident's care plan specifically included keeping the call bell within reach as a fall prevention measure. Despite this, the resident was observed twice without access to the call bell, once while sitting in a wheelchair next to the bed and again while eating breakfast. The Director of Nursing confirmed that call bells should always be within reach of residents, indicating a failure to adhere to the facility's policy and the resident's care plan.
Failure to Maintain Correct Air Mattress Settings for Residents at Risk of Skin Breakdown
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards for two residents at risk of skin breakdown. For one resident, the facility did not maintain the pressure-reducing air mattress settings as ordered by the physician. The resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was observed with the air mattress set to 85 pounds instead of the prescribed 135 pounds. Despite documentation indicating that the mattress settings were checked every shift, the incorrect setting was observed on multiple occasions, and staff were unaware of the resident's history of pressure ulcers. For another resident, the facility failed to implement the physician's order for an air mattress set between 120 and 150 pounds. The resident, who was bed-bound and at increased risk for skin breakdown, was observed with the air mattress set to 210 pounds, contrary to the physician's order. Despite documentation indicating that the mattress settings were checked every shift, the incorrect setting was observed on multiple occasions. The resident reported discomfort, and staff were unaware that the mattress was not set correctly. The facility's policy on support surfaces emphasizes the importance of pressure redistribution and individual resident needs. However, the observations and interviews revealed that the facility did not adhere to these guidelines, resulting in the failure to provide appropriate care for residents at risk of skin breakdown. The Director of Nursing acknowledged the discrepancies in mattress settings and the need for staff to check and correct settings every shift.
Failure to Supervise Elopement Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision and maintain an environment free from accident hazards for a resident identified as at risk for elopement. The resident, who had a history of bipolar disorder with psychotic features, dementia with behavioral disturbance, and severe cognitive impairment, was observed outside the facility on a patio without staff supervision. The patio had an open gate leading to a sidewalk, ramp, parking lot, and main road, posing a potential risk for elopement. The facility's policy on wandering and elopement required that residents identified as at risk should have care plans with strategies and interventions to ensure their safety. Despite this, the resident's care plan allowed for unsupervised patio time, which conflicted with the resident's identified elopement risk. The resident required substantial assistance with ambulation and had a history of being verbally abusive and having psychiatric diagnoses, further emphasizing the need for supervision. Interviews with facility staff, including a CNA and the DON, revealed that the facility had previously provided scheduled supervised outdoor time for residents, but this practice had been discontinued. The DON acknowledged that the resident was an elopement risk and should have been supervised, and that the open gate on the patio was a concern. The lack of supervision and the open gate contributed to the deficiency in ensuring a safe environment for the resident.
Failure to Provide Prescribed Diet Consistency
Penalty
Summary
The facility failed to provide food that met the individual dietary needs of a resident, who was on a physician-prescribed mechanically soft diet due to dysphagia and other health conditions. Despite the prescribed diet, the resident was offered regular consistency items and pureed meals that were not ordered or preferred. The resident expressed dissatisfaction with the food, describing it as "crappy" and "like glue," and was observed to receive meals that did not align with the prescribed diet, such as pureed pancakes and ground sausage instead of appropriately moistened and chopped items. The facility's policy required that therapeutic diets be based on individual needs and prescribed by a physician, yet the resident's meals did not adhere to these guidelines. Observations revealed that the resident was provided with meals that included pureed items and inappropriate foods like a peanut butter and jelly sandwich, which was not allowed on the resident's diet. Staff interviews indicated a lack of awareness and education regarding the specific dietary needs and restrictions of the resident, contributing to the failure to provide the correct diet. The Food Service Director acknowledged the discrepancies in meal preparation and expressed uncertainty about whether nursing staff received education on the facility's diet consistencies. The Staff Development Coordinator also confirmed a lack of diet education for nursing staff. These oversights in staff training and meal preparation led to the resident receiving meals that did not meet their dietary needs, resulting in dissatisfaction and uneaten food.
Incompatible Mattress Poses Risk of Entrapment
Penalty
Summary
The facility failed to ensure the safety of a resident by using a scoop mattress that was incompatible with the bed frame, resulting in a significant gap between the mattress and the footboard. This gap posed a risk of injury or entrapment for the resident, who had severe cognitive impairment due to dementia and was under guardianship. The resident was observed multiple times lying on the scoop mattress with a nine-inch gap at the foot of the bed, which was confirmed by the surveyor's measurements. The deficiency occurred because the facility did not follow its policy of ensuring bed safety through proper assessment and maintenance. The mattress change was made by a weekend staff nurse without notifying the maintenance staff, who were responsible for ensuring compatibility and safety. The Director of Nursing admitted that no safety audit was conducted at the time of the mattress change, and the facility lacked a specific policy for auditing bedframe or mattress safety, relying instead on quarterly audits by the maintenance department.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Palmer
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hampden Post Acute | 4.8 mi | ★★★★★ | 9 | 0 |
| Life Care Center Of Wilbraham | 6.1 mi | ★★★★★ | 0 | 0 |
| Vantage At Hampden Llc | 9.4 mi | ★★★★★ | 0 | 0 |
| Sixteen Acres Health And Rehabilitation Center Llc | 10.3 mi | ★★★★★ | 10 | 0 |
| Chicopee Rehabilitation And Nursing | 10.8 mi | ★★★★★ | 0 | 0 |
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