The violations earned the facility an immediate jeopardy citation — the most serious level of harm — during an April inspection. Inspectors documented cases where residents received inadequate care across multiple areas, from medication management to wound treatment.
The most egregious case involved a nurse who entered an antibiotic order for a resident under a nurse practitioner's name without authorization. The resident's family had requested the medication be resumed from a previous prescription, but it had expired before the resident's hospitalization. When the nurse practitioner discovered the unauthorized order, she immediately placed it on hold.
"Nursing staff ordered rifaximin under Nurse Practitioner's name without order or permission," the provider wrote in progress notes. The medication had been administered for several days before the unauthorized order was discovered.
The Director of Nursing told inspectors she was unaware staff were entering medication orders without provider approval. "Staff should not order medication under the provider's name without permission," she said. "That was a violation of the nurses' license and corrective action should be taken."
Another resident suffered through a two-week decline with pneumonia, sepsis, and kidney inflammation before staff finally called 911. The resident, identified as R #1, began complaining of cough and lung congestion on January 17. Over the following days, nursing notes documented escalating symptoms: confusion, disorientation, and lethargy.
By January 25, staff noted "new onset of confusion" and documented the resident "stated she should walk out of the facility and she was seeing her pet cat walk around the room." Lab work was ordered but no emergency care was provided.
The resident's condition continued deteriorating. On January 29, a provider noted elevated white blood cell count and ordered a chest x-ray to rule out pneumonia, but still did not send the resident to the hospital. Two days later, nursing staff finally called 911 when the resident's blood pressure dropped to 74/42 and she became "lethargic, difficult to arouse when name is being called, pale, and clammy."
Hospital doctors diagnosed pneumonia, urinary tract infection, kidney inflammation, and sepsis.
Multiple staff members acknowledged the delay was inappropriate. A Licensed Practical Nurse who worked with the resident on January 25 said she "believed R #1 should have been sent to the ER sooner than 01/31/25." Another LPN confirmed "R #1 should have been sent to the ER sooner than she was sent out."
The resident's friend told inspectors the facility "delayed sending R #1 to the ER." The resident herself confirmed that "her friends and roommate had concerns that the facility delayed sending her to the ER."
A Physician's Assistant who evaluated the resident said she "should have been sent to the ER sooner than she was and she did not know why R #1 was not sent to the ER sooner."
In another case, family members spent two weeks trying to get treatment for a resident's infected eyes. R #7's daughter emailed facility staff on December 24 and December 31 about her mother's red, irritated eyes, but received no response until January 7.
During the Christmas holidays, three different family members noticed the resident's eye problems during visits. A cousin who visited in person alerted staff and they provided eye drops, but no medical evaluation occurred.
The resident was finally diagnosed with allergic conjunctivitis on January 7, nearly two weeks after the first family complaint. The Administrator acknowledged that staff should have immediately informed nurses of the resident's condition change, but "there was no evidence that this was done for R #7."
Inspectors also found systematic failures in basic care protocols. One resident was receiving oxygen at 2.5 liters per minute when physician orders specified 5 liters per minute. A Certified Nursing Assistant told inspectors "she did not know what LPM R #1's O2 should be at and the CNAs put R #1's O2 at 2.5 LPM."
Oxygen tubing for multiple residents was not labeled or dated as required by physician orders. Staff confirmed the violations but had not corrected them.
Another resident received oxygen for days without any physician order. The Director of Nursing confirmed "R #3 did not have physician orders for O2 use and stated R #3 should have had physician orders for O2 use."
Assessment failures compounded the care problems. Staff failed to document multiple pressure ulcers on discharge paperwork, understating the severity of one resident's wounds. A resident admitted with two Stage 1 pressure ulcers and one Stage 4 ulcer developed additional wounds during the stay, but discharge assessments were incomplete and inaccurate.
The MDS Coordinator told inspectors she relied on medical records and assumed they were accurate, only questioning staff "if something in the records is changed or seems out of place."
One resident's baseline care plan failed to include oxygen therapy despite daily use. The resident's power of attorney confirmed oxygen was prescribed at the hospital and continued at the nursing home, but staff never incorporated it into the care plan. The Director of Nursing acknowledged "R #3's O2 use was not care planned on his baseline care plan, and stated that it should have been."
The inspection revealed a pattern of delayed responses to resident deterioration. R #10, a resident with Alzheimer's disease and stroke damage, experienced multiple incidents of delayed care. When staff suspected a urinary tract infection on November 3, the resident's outside provider canceled facility-ordered tests and promised to enter antibiotic orders. The antibiotic order wasn't entered until five days later.
Two weeks later, the same resident exhibited severe agitation — screaming and attempting to throw herself on the floor. The provider was called and ordered psychiatric medication, but the order wasn't entered for 14 days.
The Director of Nursing confirmed these delays were inappropriate. "R #10's care was delayed" in multiple instances, she told inspectors.
Staff interviewed by inspectors consistently acknowledged the facility's failures. One LPN said she "tried to send R #1 to the ER before, but she was told she could not do that by the former Unit Manager." Another nurse confirmed residents "should have been sent to the ER sooner."
The Director of Nursing told inspectors she "would expect facility nurses to send a declining resident to the ER if needed, and not wait to do so."
The violations occurred despite the facility's responsibility to provide professional standards of care and respond promptly to changes in residents' conditions. Inspectors noted that delayed treatment and inadequate monitoring put residents at risk of adverse outcomes and unnecessary suffering.
R #1's friend described watching the resident's progressive decline over the two-week period before hospitalization, while R #7's daughter had to make multiple attempts to get basic eye care for her mother during the Christmas holidays.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Las Palomas Center from 2025-04-03 including all violations, facility responses, and corrective action plans.