Las Palomas Center
Las Palomas Center in Albuquerque, NM — inspection on July 19, 2024.
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
Review of AA's personnel record revealed the AA was hired on 04/22/24.
The record revealed the AA had been working in direct contact with residents on a full-time basis since her date of hire and there was no evidence of the employee completing any abuse training prior to 07/17/24 when the survey [NAME] requested it.
During an interview with the AA and the Corporate Activities Director on 07/17/24 at 12:34 PM, the AA stated she had never received the facility's employee orientation.
She confirmed no facility training related to abuse and neglect had ever been conducted with her since her date of hire and confirmed she had been working directly with residents since her date of hire.
The Corporate Activities Director stated all employees were expected to receive the facility's abuse training prior to working in direct contact with any resident.
During an interview on 07/17/24 at 1:56 PM, the Administrator indicated the AA had been through some of the training required for orientation to the facility and she had 90 days after her date of hire to finish all of the required training.
The Administrator was not able to provide any documentation to show any of the completed training included the facility's required abuse training.
325036
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 325036 B.
Wing 07/19/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Las Palomas Center 8100 Palomas Avenue NE Albuquerque, NM 87109
The survey team validated that the IJ was removed on 07/19/24 at 6:50 PM following verification conducted onsite that the
jeopardy to resident health or safety The deficient practice remained at an E (pattern with potential for minimal harm) scope and severity following the removal of the IJ.
The Plan of Removal included:
Resident #78's smoking assessment was updated 7 /19/24 at to ensure accuracy and has been identified as a supervised smoker.
Her care plan was updated to reflect this.
Her room and person were observed for smoking material and none was found, as she was compliant in providing her smoking material to the staff when asked.
She was re-educated on the smoking policy and agreed to follow the policy.
Family was notified of policy as well (highlighted on the list of emails provided).
She does have a history of non-compliance and was given a behavioral contract on 7 /18/24. If she does not adhere to the policy, she will be given a 30-day discharge notice.
All residents who smoke were assessed by licensed nursing staff on 7/18/2024 with no injury identified related to smoking.
The Administrator/designee began individual meetings with smokers on 7/18/2024 and completed meeting on 7 /19/24 by 3:00pm for the identified residents who smoke at the center to review the smoking policy/process, and/or initiate behavioral contract which includes the following (notes will be in chart that indicate the smoking policy review, and behavior contracts will be uploaded in the chart)
The Administrator/designee compiled a list of residents who smoke at the center 7/19/2024 to be placed at the nurses station and will be updated as needed. A whole house sweep of resident smoking materials will be completed on 7 /19/24 by 3:30pm by the
Administrator/designee to ensure no items are observed in the resident rooms or observed on the resident and will be obtained if found, or a behavioral contract will be initiated if they do not agree to give up items.
325036
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 325036 B.
Wing 07/19/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Las Palomas Center 8100 Palomas Avenue NE Albuquerque, NM 87109
Review of R19's significant change Minimum Data Set (MDS) with an assessment reference date (ARD) of 06/14/24 located in the electronic medical record (EMR) under the MDS tab revealed the facility assessed R19 to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact.
Review of R19's Progress Note dated 05/30/24 in the EMR under the Progress Notes tab revealed that the nurse was made aware that R19 was not at baseline vitals. R19 was transported to the hospital via emergency medical services (EMS) due a drop in blood pressure and a low oxygen saturation level of 88% on 4 liters of oxygen.
The resident was sent back to the facility on [DATE].
Review of the complete medical record for R19 revealed no evidence that a written transfer was provided to the resident.
During an interview on 07/16/24, at 9:30 AM, R19 was asked if he had received written notice of the transfer. R19 stated, No.
2.
Review of R81's significant change MDS with an ARD of 06/08/24 in the EMR under the MDS tab revealed the facility assessed R81 to have a BIMS score of three out of 15, indicated the resident had severe cognitive impairment.
Review of R81's Progress Note dated 06/30/24 in the EMR under the Progress Notes tab revealed the resident was sent to the hospital after a change in vital signs.
The resident was sent back to the facility on [DATE].
Review of the complete medical record for R81 revealed no evidence that a written transfer was provided to the resident and/or representative.
During an interview on 07/16/24 at 3:15 PM, Family Member (FM)21 was asked if she had received anything in writing when the resident was sent to the hospital. FM21 stated, No.
325036
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 325036 B.
Wing 07/19/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Las Palomas Center 8100 Palomas Avenue NE Albuquerque, NM 87109