Palomino Place

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents had the right to be free from abuse for 1 of 5 residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 was protected from Resident #2 who entered her room and engaged in non-consensual sexual contact with her on 5/21/2026. The failure placed residents at experiencing fear, emotional distress, and unwanted sexual contact, placing residents at risk for abuse and psychological harm.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 5 (Resident #38, Resident #80, Resident #90, Resident# 57 and Resident #18 ) of 16 residents reviewed for quality of life The facility failed to ensure: Resident #38 had his nails cut and cleaned. Resident #80 had her fingernails cleaned and trimmed and chin hair shaved. Resident #18 has his fingernails trimmed. Resident #90 had her fingernails cleaned and trimmed. Resident #57 had her fingernails trimmed and her chin hair shaved. These failures could place residents at risk for not receiving necessary care and services and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences for two of three residents (Resident #50, and Resident #26) reviewed for respiratory care. 1. The facility failed to ensure LVN K maintained sterile/aseptic technique during tracheostomy care (a surgical opening in the neck providing a direct airway through the trachea) for Resident #50 on 10/02/25. 2. The facility failed to ensure Resident #26's had a physician order prior to administering oxygen on 9/30/25. These failures could place residents at risk for respiratory infections and at risk of receiving an incorrect amount of oxygen. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to establish and maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 7 of 15 residents (Resident #72, Resident #73, Resident #79, Resident #80, Resident # 78, Resident # 21 and Resident #39) reviewed for infection control. 1. The facility failed to ensure CNA F and RA D utilized Enhanced Barrier Precautions and performed hand hygiene before and after checking Resident #72 for incontinence on 10/01/25. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary and comfortable environment for 1 of 8 residents (Resident #64) in that:Resident # 64's refrigerator in her room had food that was moldy and spoiled half-filled cup of coffee on 9/30/2025. This failure could place resident at risk for a diminished quality of life and a diminished clean, homelike environmentThe

Inspectors wroteBased on interview, observation and record review, the facility failed to complete an assessment that accurately reflects a resident's status for 1 of 5 residents (Resident #26) reviewed for accuracy of assessments. The facility failed to accurately complete Resident #26's Quarterly MDS Assessment related to the need for oxygen therapy. The facility failed to accurately complete Resident #26's Quarterly MDS Assessment related to the discontinued use of anti-coagulant therapy. This failure could place the resident at risk of not having met her needs.

Inspectors wroteBased on interviews and record review the facility failed to include in the care plan services that will be provided to the resident for 1 (Resident #40) of 10 residents reviewed for comprehensive care plans. The facility failed to ensure Resident #40 was care planned for ADLs. This failure could put Residents at risk of receiving unnecessary treatments, not receiving care or services and further decline of their physical health.

Inspectors wroteBased on interviews and record reviews, the facility failed to have the comprehensive care plan reviewed and revised by qualified persons after each assessment for 1 (Resident #26) of 10 residents reviewed for comprehensive care plans. The facility failed to update Resident #26's care plan to reflect doctor's orders to discontinue anticoagulant therapy on 8/14/25. This failure could put Residents at risk of receiving unnecessary treatments, not receiving care or services and further decline of their physical health.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure, based on the comprehensive assessment of the resident, a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one of three residents (Resident #73) reviewed for incontinence care. The facility failed to ensure CNA F and RA D provided appropriate perineal care for Resident #73 when they failed to clean the resident's perineal area, separate the labia and wash downward and clean the inner thighs and groin area on 10/01/25. This failure could place residents at risk for the development and/or worsening of urinary tract infections and skin breakdown. Record review of Resident #73's quarterly MDS assessment, dated 09/01/25, reflected a [AGE] year-old female with an admission date of 02/28/24. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles and in compliance with the state laws and regulations, which included the appropriate accessory and cautionary instructions and the expiration date when applicable for the facility's one of two (Whirlaway med room) medication rooms reviewed for storage. The facility failed to ensure a vial of Tuberculin Purified protein derivative (substance used for skin test for tuberculosis), that was opened and used, was dated and stored in its original package in the medication room refrigerator. This failure could place residents at risk of diminished effectiveness and not receiving the therapeutic benefits of the medications.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure residents toileting facilities were adequately equipped to allow residents to call for assistance for 2 Residents (Resident #57 and Resident #64 ) of 16 residents reviewed for residents' call systems. The facility failed on 09/30/2025 to ensure the call light system was accessible to a resident, lying on the floor in the shared residents' toilets located inside the residents' rooms when the call lights were missing the pull strings, for: Resident #57 and Resident #64 This failure could place residents in the facility at risk of being unable to have a means of directly contacting caregivers from their restroom.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one (Resident #1) of three residents reviewed for pharmacy services. The facility failed to ensure Resident #1, who was NPO, did not receive a medication by mouth. The failure could place residents at risk for aspiration, choking, and death. An IJ was identified on 08/26/25. The IJ template was provided to the facility on [DATE] at 4:49 PM. While the IJ was removed on 08/27/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimum harm because all staff had not been trained on the Plan of Removal.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 (Resident #1) of 3 residents reviewed for pressure ulcers. CNA A and CNA B failed to reposition Resident #1 as required by her orders and care plan on 07/30/25. The facility failed to ensure that Resident #1 did not develop 2 stage III wounds while at the facility. This failure could place residents with pressure wounds at risk of the wound worsening, leading to increased pain, infection, delayed healing, serious complications including sepsis, reduced mobility, and a lower quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 (Resident #1) of 2 residents reviewed for catheter care. The facility failed to ensure Resident #1 had a catheter anchor in place during wound care on 07/30/25. This failure could place residents with foley catheters at risk for pulling and/or trauma to the bladder and urethra.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that residents are free of any significant medication errors for 1 of 1 resident (Resident #1) reviewed for medication administration. The facility failed ensure Resident #1, who was at increased risk for stroke due to having history of heart failure and persistent atrial fibrillation as per hospital discharge records dated 05/29/25, was administered her physician-ordered warfarin (Coumadin); which resulted in the resident being sent to emergency room after developing drooping of the left side of the face and slurred speech. An Immediate Jeopardy was identified on 06/26/25. The IJ template was provided to the facility on [DATE] at 03:46:PM. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #1) of 6 residents reviewed for pharmacy services. The facility failed to ensure employees with access to controlled medication properly counted the inventory of the controlled medications. LVN A and LVN B did not adequately count the inventory on their medication cart, and it was later discovered that 120 tablets of Oxycodone (a controlled narcotic drug), belonging to Resident #1, was missing from the medication cart. The medications were never located. The noncompliance was identified as past noncompliance (PNC). The noncompliance began on 10/09/24 and ended on 10/11/24. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary services for residents who were unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident #203) of 8 residents reviewed for quality of life. The facility failed to ensure Resident #203's hair was washed while she was at the facility. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure fluid intake to maintain proper hydration for two (Resident #1 and Resident #45) of four residents reviewed for hydration status and maintenance was available. 1. The facility failed to offer fluids that were accessible for Resident #1 and the facility failed to offer extra fluids at mealtime for Resident #1 as indicated in the resident's comprehensive plan of care. 2. The facility failed to offer fluids that were accessible for Resident #45 and the facility failed to offer extra fluids at mealtime for Resident #45 as indicated in the resident's comprehensive plan of care. These failures could increase the resident's risk for dehydration, skin breakdown and weight loss. Findings Include: [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 (Resident #45) of 8 residents reviewed for pharmacy services. The facility failed to document on the Medical Administration Record and Treatment Administration Record for August 2024 that Resident #1 was receiving Hydrocodone 10 mg-acetaminophen 325 mg (pain medicine). These failures could place residents at risk for medication errors, ineffective relief from pain medication, and drug diversion of controlled substances.

Inspectors wroteBased on interview and record review, the facility failed to ensure, based on the comprehensive assessment of a resident, residents who had not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 5 residents (Resident #44) reviewed for unnecessary psychotropic medications. The facility failed to provide an appropriate diagnosis for Resident #44's use of Olanzapine (Atypical antipsychotic used to treat schizophrenia and bipolar disorder). These failures could put residents at risk of receiving unnecessary psychotropic medications.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that menus were followed for the lunch meal served on 08/21/24 to meet the nutritional needs for 7 of 24 regular diet plates served. 1. The facility failed to serve 7 of 24 observed lunch trays with the appropriate and sufficient serving of chicken for lunch on 08/21/24. These failures could place residents at risk of decreased food intake, weight loss and an increased risk of aspiration. Interview on 08/21/24 beginning on 11:00AM during a confidential resident group meeting with 7 facility residents revealed that residents are served inadequate portions. The confidential resident group meeting revealed that several resident's were concerned with the portion sizes they are served as they are still hungry after they finish their meal and have to ask for more food or a snack after they finish their meals. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide food that was palatable, appetizing and served at safe temperatures for 1 (08/20/24-Lunch) of 2 meals reviewed for temperature, taste and palatability. 1. The facility failed to serve food that was palatable and appetizing for Resident #3 for lunch on 08/20/24. 2. The facility failed to ensure desserts served during lunch service on 08/21/24 were tested for safe serving temperatures before serving to residents. These failures could place residents at risk for weight loss, altered nutritional status and food borne illnesses. Findings Included: 1. Record Review of Resident #3's admission MDS with an ARD of 08/16/24 revealed an [AGE] year-old male who admitted to the facility on [DATE]. Resident #3's active diagnoses included: Dysphagia (Difficulty Swallowing) and Urinary tract infection. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was prepared and served according to the resident's assessment, plan of care, and in a form designed to meet the resident's needs for two (08/20/24- Lunch and 08/21/24- Lunch) of three meals reviewed for resident's needs. 1. The facility failed to follow Resident #3's physician order for nectar thickened liquids on 08/20/24. 2. The facility failed to provide pureed wheat bread in a smooth, palatable and pudding-like consistency on 08/20/24 and 08/21/24 3. The facility failed to serve 7 of 24 observed lunch trays with the appropriate and sufficient serving of chicken for lunch on 08/21/24. These failures could place residents at risk of decreased food intake, weight loss and an increased risk of aspiration. Findings Include: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had a right to personal privacy that included accommodations for one (Resident #153) of nine residents reviewed for resident rights. The facility failed to ensure Resident #153 was provided with privacy when receiving tracheostomy care. This failure placed residents at risk for their privacy being violated and a decrease in their quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #45) of 8 residents observed for infection control. CNA B failed to perform hand hygiene or change her gloves after providing incontinence care for Resident #45. This failure could place residents at risk for healthcare associated cross contamination and infections.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to resolve a grievance in a timely manner for 1 of 4 (Resident #1) residents reviewed for grievances. The facility failed to notify residents or their representatives on how to file a grievance in an anonymous manner, their right to obtain a written decision regarding their grievance and the correct information for the facility grievance official for 4 (Resident #1, Resident #2, Resident #3, Resident #4) out of 4 residents reviewed for grievances. 1. The facility failed to make prompt efforts to ensure Resident #1's Representative's request to file a grievance was initiated and resolved in a timely manner. 2. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 1 resident (Resident #6) reviewed for pharmacy services. Resident #1's narcotic pain medication was not accurately received as required. DON on 7/25/24 at 10:15am revealed the medication was delivered by a general shipping company. The medication was left unsecured as revealed by none of the staff receiving the medication and resulted in the medication not being accounted for resulting in a drug diversion. This failure could place residents at risk of misappropriation by drug diversion, and could result in increased pain, and poor quality of life. The noncompliance was identified as Past Noncompliance (PNC). [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that drugs and biologicals were stored and labeled in accordance with accepted professional principles for 1 (800 hall Medication Aide Cart) of 3 medication carts . 1. The facility failed to ensure that medications already opened, and in-use were dated and labeled on the date they were initially opened on the 800 hall MA (Medication Aide) cart. 2. The facility failed to ensure that there were loose medications on the 800 MA (Medication Aide) cart that were unidentified. These failures could place residents at risk for adverse pharmaceutical reactions. Findings Included: Observation and audit of the facility 800 hall MA cart on 07/26/24 at 2:15pm, during 6am-2pm shift and 2pm-10pm shift change revealed the following: 1. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (CMA C and LVN B) of 4 staff members reviewed for infection control practices. 1. CMA C failed to preform hand hygiene before and after medication administration. 2. LVN B failed to follow safe infection prevention practices by placing gloves on before entering a patient's room, entering the Resident's room to provide care, failing to preform hand hygiene before and after care, and exiting the patients room with gloves on. [...]

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure an environment that was free of accident hazards and that each resident received adequate supervision to prevent elopement for 1 (Resident #1) of 6 residents reviewed for quality of care. 1. The facility failed to ensure Resident #1 was provided with adequate supervision to prevent him from eloping from the facility on 01/22/2024. 2. The facility failed to ensure staff recognized Resident #1 eloped and recognize Resident #1 as a resident of the facility when Resident #1 was encountered outside the 500 Hall door. 3. RN A failed to follow their elopement response policy when the 500 Hall door alarm sounded. The facility concluded Resident #1 eloped through the facility's 500 Hall exit and staff did not conduct a thorough search of the facility and its grounds when the alarm sounded. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide food that was palatable for 5 (Resident#8, Resident#31, Resident#36, Resident#49 and Resident#69) of 23 residents who were interviewed regarding room trays and dining room trays from the facility's only kitchen. 1. The facility failed to serve food that was palatable. 2. Test tray lunch meal were served bland (lack of taste or flavor). These failures could affect the residents who ate and had their meals prepared by the facility kitchen by placing them at risk of weight loss, altered nutritional status, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary services to maintain good personal hygiene for one (Resident #76) of eight residents reviewed for ADL care. The facility failed to provide Resident #76, who required extensive assistance, with timely incontinent care on 7/17/23. This failure could place residents at risk of not receiving necessary care and services to maintain skin integrity and self-esteem.