Palm Springs Post Acute
PALM SPRINGS POST ACUTE in CHELMSFORD, MA — inspection on March 26, 2026.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
should be documenting the appearance and specific characteristics of Resident #1's wounds with
mistakenly removed.On 03/26/26, the Facility was found to be in Past Non-Compliance, with an
areas of concern as evidenced by:A) On 03/15/26 the Director of Nurses educated the nursing staff on Wound Treatment Documentation requirements with mandatory documentation after every wound treatment to include:*Wound Location*Wound Measurements*Wound Appearance*Drainage*Odor*Peri Wound Skin Condition*Signs of InfectionB) On 03/15/26 the Director of Nurses educated the nursing staff on required documentation elements, including supplemental documentation inclusive of wound characteristics.C) On 03/15/26 a facility wide audit was initiated for all residents with wound orders to validate documentation elements in place, and completeness of documentation.D) Weekly wound documentation audits will be conducted weekly x 4 weeks and then monthly x 2 months.E) The Director of Nurses will review audit findings and trends and bring to monthly Quality Assurance Performance Improvement (QAPI) and Wound Committee meetings.F) The Director of Nurses and/or Designee are responsible for overall compliance.
225508 03/26/2026
Palm Springs Post Acute 40 Parkhurst Road Chelmsford, MA 01824
Review of Resident #1's MAR, dated 02/11/26, indicated there was no
aware Resident #1 refused to participate in therapy at times and it was due to his/her fatigue and low
pain medication administration and determine if pain was an on-going issue.
The DOR said she was only aware of Resident #1's refusals to get out of bed.Review of Resident #1's Physician's Orders for February 2026 indicated he/she had orders for the following:-Methocarbamol (muscle relaxant) 500 milligrams (mg) one tablet by mouth three times per day for muscle spasm- discontinued on 02/05/26.-Acetaminophen (non-prescription analgesic) 325 mg give two tablets every four hours as needed for mild pain.-Acetaminophen 500 mg give one tablet by mouth every six hours as needed for pain.Review of Resident #1's Medication Administration Record (MAR) for the month of February 2026 indicated that although Resident #1 reported and displayed signs and symptoms of pain during several Physical Therapy Treatments and the PT Notes indicated he/she was either premedicated and/or received prescribed medications, there was no documentation to support that nursing administered Resident #1 an analgesic from 02/06/26 through 02/12/26.Review of Resident #1's Nurse Practitioner #1's Progress Note, dated 02/11/26, indicated Resident #1 had increased tenderness to his/her sacral pressure ulcer.
The Note indicated that Resident #1 had declined to get out of bed due to bilateral hip pain but did participate in bed exercises with PT and he/she had Tylenol ordered for pain management as needed.During a telephone interview on 03/27/26 at 9:04 A.M., Nurse Practitioner (NP) #1 said that she had visited Resident #1 multiple times during his/her stay at the facility. NP #1 said she was unaware that Resident #1 was reporting pain during several Physical Therapy visits and if she had known she would have initiated a new pain management plan, especially if his/her pain was a barrier for him/her to complete therapy sessions. NP #1 said she had discontinued Resident #1's scheduled Methocarbamol due to him/her having increased lethargy. NP #1 said she was unaware that nursing had not administered Tylenol to Resident #1.Nurse Practitioner (NP) #1 said other indicators of pain included facial grimacing, not getting out of bed or moving as well. NP #1 said if Resident #1 had been displaying those behaviors the nursing staff could have offered him/her Tylenol.During a telephone interview on 03/27/26 at 1:21 P.M., the Director of Nurses (DON) said that the departments should be talking to each other and if Resident #1 had signs and symptoms of pain during PT visits, nursing staff should have been notified and should have followed through.
The DON said if there is communication between departments, it should be documented in a progress note.
225508 03/26/2026
Palm Springs Post Acute 40 Parkhurst Road Chelmsford, MA 01824
and Wound Committee meetings.F) The Director of Nurses and/or Designee are responsible for overall