Palmer Healthcare Center

In the surveyor’s words

From the most serious findings on record at Palmer Healthcare Center, in the surveyor’s own words.

• Actual harm, isolatedF580May 20, 2022

  Based on observation, record review and interview, the facility failed to ensure staff notified the physician about signs of a wound infection for one Resident (#23) out of two applicable sampled residents. Findings include: Resident #23 was admitted to the facility in March 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a progress note, dated 4/10/22, indicated the Resident had a large blister on the back of the right heel measuring 6 centimeters (cm) x 8 cm with a small opening that was draining serous sanguineous drainage (a thin and watery fluid that is pink in color due to the presence of small amounts of red blood cells). […]

• Actual harm, isolatedF686May 20, 2022

  Based on observation, record review and interview, the facility failed to ensure staff provided treatment and repositioning to prevent a pressure ulcer injury from worsening for one Resident (#23) out of 2 applicable sampled residents. Findings include: Resident #23 was admitted to the facility in March 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Minimum Data Set (MDS) assessment, dated 2/24/22, indicated the Resident required extensive assist of two for both bed mobility and transfers and was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 0 out of 15. […]

• No harm, potential for more than minimal, widespreadF812Sep 26, 2024

  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. […]

• No harm, potential for more than minimal, widespreadF801Aug 10, 2023

  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. […]

• No harm, potential for more than minimal, patternF812May 20, 2022

  Based on document review, observation and interview, the facility failed to ensure that staff maintained professional standards for the storage of food and the operation of the dishmachine, to help minimize the risk of food-borne illnesses. Findings include: Review of the facility's Family/Visitor Provided Food policy, dated 1/9/17, indicated the following: -Nurse, or their designee, will take the food/beverage and label the received product with a general description of the food/beverage, the resident's name, their room number and date the product was received from the visitor. On 5/19/22 at 10:18 A.M., the surveyor observed the refrigerator/freezer appliance in the unit kitchenette. […]