La Paloma Healthcare Center

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure a Minimum Data Set (MDS) assessment was accurately coded for a resident who discharged to the hospital for 1 (Resident #84) of 3 residents reviewed for closed records.

Inspectors wroteBased on interview, observation, record review, and facility policy review, the facility failed to follow physician orders for 1 (Resident #6) of 2 residents reviewed for skin conditions. Specifically, Resident #6 had an order, dated 03/26/2025, to schedule a dermatology appointment. However, no attempts were made to schedule a dermatology appointment until 04/15/2025.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to follow the pharmacist's recommendations for 1 (Resident #6) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to offer the influenza vaccine and provide education regarding influenza immunizations for 1 (Resident #32) of 5 residents reviewed for immunizations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure fall safety interventions for two of six residents (Resident 35 and Resident 23) reviewed for accidents were provided when: Resident 35's chair/bed silent alarm (an alarm used to help warn staff when a resident is changing position or getting up) was not implemented consistently; In addition, Resident 35's falls were not thoroughly investigated to ensure that all fall preventative measures were implemented. Resident 23's wheechair was placed in an area that was not within the resident's reach. In addition, the facility was not secured during the night when a visitor's entrance was left open and unlocked. As a result, Resident 35 fell eight times while at the facility. One of Resident 35's fall resulted in a laceration on the forehead which required suturing. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to use pressure relieving mattresses as ordered for 4 of 9 residents sampled for pressure related injuries (24, 53, 66, 16). In addition, 1 resident (16) was not repositioned as ordered. As a result, there was the risk of skin breakdown.

Inspectors wroteBased on interview and record review, the facility failed to answer call lights in a timely manner to meet the needs of the residents for 6 out of 10 confidential residents (A, B, C, D, E, and F) and 6 of 22 sampled residents (13, 53, 23, 41, and 71) and 1 unsampled resident (222). This failure had the potential to result in residents not receiving needed services timely and efficiently.

Inspectors wroteBased on interview and record review, the facility failed to implement a policy to prevent abuse for one resident (Resident 2), when the facility did not follow abuse reporting requirements after the resident reported the incident to the staff. This failure had the potential to compromise resident safety.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of abuse was reported in a timely manner for one resident (Resident 2). This failure had the potential to compromise Resident 2 and other residents' safety.

Inspectors wroteBased on interview and record review, the facility failed to identify and investigate an alleged abuse violation and protect one resident (Resident 2). This failure had the potential to result in physical and emotional harm for Resident 2 and other residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop safe discharge planning for one of three residents (Resident 2) reviewed for discharge. This failure had the potential to result in Resident 2 being discharged to a facility that may not be able to meet his needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a physician ordered medication (a laxative -medication to promote bowel movements) was administered to one of three residents (Resident 28) during the medication administration observation. This deficient practice had the potential for Resident 28 to experience constipation (bowel movements that were difficult to pass).

Inspectors wroteBased on interview and record review, the facility failed to ensure the use of as needed psychotropic medication (a medication which effects the mind) was limited to 14 days for 1 of 5 residents sampled for unnecessary medications (Resident 13.) As a result, there was the risk of Resident 13 receiving unnecessary medication.

Inspectors wroteBased on interview and record review, the facility failed to accurately document the decision maker for one of 22 residents (Resident 2) reviewed for medical record accuracy. This failure resulted in confusion among facility's staff and had the potential for delay in medical treatment.

Inspectors wroteBased on interview and record review the facility's Quality Assurance Performance Improvement (QAPI) committee failed to thoroughly and completely identify and implement areas of their fall prevention program. This resulted in findings of multiple falls for Resident 35, including a fall with injury. See F656, and F689.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure transmission-based precautions (measures used to prevent spread of infection) were appropriately implemented per infection control standards, for 4 of 6 residents (Residents 19, 475, 477, & 478), when: 1. Resident 19 and Resident 475 were placed together in one room while each resident required a different type of transmission-based precautions. 2. Three residents on transmission-based precautions had the doors open. These failures had the potential to increase the risk of infection for other residents and staff in the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide evidence of nursing staff competencies (evidence the nursing staff had the knowledge and skills required for their role) for three of three LNs (1, 2, and 3). As a result, there was the potential for resident care to be compromised due to the lack of knowledge and skills of the nursing staff.

Inspectors wroteBased on dietetic services staff observation, interviews, and document reviews the facility failed to ensure safe and effective Dietetic Services oversight in accordance with the facility contract. Failure to ensure effective oversight of day to day dietetic services operations could place 88 residents at nutritional risk, and in turn, further compromise their medical status.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure: 1. The pureed (food blended to the consistency of applesauce or milkshake thick liquid) diet recipe was followed for nine residents; 2. The fortified diet was followed for 22 residents; and, 3. The therapeutic menu was followed for a renal diet. These failures had the potential to provide meals that did not meet the nutritional needs of residents who received puree, fortified, and renal diets and further compromise their health status.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure sanitary conditions were maintained during food storage when: 1. Two of 14 onions which had black discoloration were not discarded; 2. Two of seven dried cereal bowls were not discarded 24 hours after being prepared and one was not discarded 48 hours after being prepared; 3. Three serving scoops were dirty with green and brown crusted substances and were stored with clean serving utensils; 4. Sixteen plastic bowls were stored wet underneath a food prep counter; and, 5. Three light bulb panels directly above the food preparation area and tray line station were exposed and uncovered. These failures had the potential to cause widespread food borne illness among residents who consume food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 18 sampled residents (4) was assisted with feeding in a respectful manner. This failure had the potential to negatively impact Resident 4's self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the use of a hearing aid for one of three residents (66) with impaired hearing. As a result, there was a potential for Resident 66 to experience decreased socialization and isolation.

Inspectors wroteBased on observation, interview, and record review the facility failed to accurately assess the skin for one of 18 sampled residents (42). In addition, Resident 42's care plan was not revised when the resident's skin was reassessed by the physician and the skin issue was resolved. This inaccurate skin assessment and failure to revise the resident's care plan had the potential for confusion and miscommunication among staff and affect Resident 42's care.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide proper supervision during a shower for one of 18 sampled residents (41). This failure resulted in Resident 41 falling from a shower chair and hitting his head.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer a PRN (as needed) medication for constipation per the physician's order for one of two residents (4), reviewed for constipation. As a result, Resident 4 experienced abdominal discomfort and an episode of fecal impaction (hardened stool stuck in the rectum) one month prior. This failure also had the potential to cause a bowel obstruction (a blockage of the intestines).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff for the food and nutrition services department competently carried out kitchen duties in a safe, and sanitary manner when: 1. A staff member was unable to verbalize and demonstrate correct techniques related to testing sanitizer buckets; and 2. A staff member was unable to demonstrate the correct technique for testing the sanitation level on the dishwasher. These practices had the potential for residents to be exposed to food borne illness, due to lack of staff training and monitoring of their duties.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary practices were implemented for resident's food brought in from the outside. Failure to ensure safe food storage and reheating procedures for residents' food brought in from the outside had the potential to result in foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to administer a vaccine in a timely manner for one of 10 sampled residents (74). As a result, Resident 74 was not vaccinated for influenza (flu) during influenza season, and had the potential to contract and spread influenza.