Las Palomas Center

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

10/22/2025, 10/29/25 all care plans were audited and accurate per wound orders Starting on 10/31/2025 direct care staff were re-educated on Wound Documentation and inputting orders upon admission.Systemic Measures Starting 10/30/2025 the Center Nurses will be re-educated on the following areas by the Nurse Educator/Designee. Nurses will be re-educated on completion of skin assessments weekly per schedule.

Nurses will be educated on their responsibility with communication with management and provider for the change in condition process/documentation when a resident is having a change in condition (including new or worsening wounds). On 10/30/2025 Nurses will start to be educated on Genesis wound processes which include the DIMES, timely and accurate identification and documentation for wounds/wound changes, change in condition process, and appropriate treatment/intervention implementation upon identification of new or worsening wounds. CNA's will be educated on the change in condition process for CNA's (including skin changes) and stop and watch.As of 10/31/2025 100% of available staff have been educated on these processes. Any staff member that has not been scheduled, on leave of absence (FMLA), vacation, or PRN staff will be educated prior to returning to their next shift. Quality Assurance & MonitoringThe Director of Nursing/Designee will audit education sign-off sheets to ensure that all nursing staff receive the education mentioned above. The Director of Nursing/Designee will conduct 5 random audits of Residents that have wounds for skin assessment, order accuracy and for wound care process abidance. This will be audited weekly for 12 weeks.An Ad Hoc QAPI Meeting was held on 10/22/2025 to approve the above plan.The DON/designee and the Administrator/designee will bring the results of the audits to the QAPI committee for tracking, trending and further recommendations to ensure compliance with the plan. The audits will be brought to the QAPI committee for 3 months. The Administrator will oversee the QAPI committee.The Plan of Removal was approved on 11/04/25. The Immediate Jeopardy was removed as of 10/31/25 and the scope and severity was reduced from J to D.The POR was verified as follows:Record review confirmed full house audit of all residents to identify any wounds. On 11/05/25 at 11:00 am the Plan of Removal was verified when LPN #1, 2, 3 and Registered Nurse (RN) #1 each interviewed and stated they had been provided training on 10/31/25 which included reviewing all admitting orders for all residents, verifying the admitting orders with the facility provider and entering the admitting orders in each resident's EMR. All four nurses confirmed their training included monitoring all residents for daily wound care orders completing wound care orders and then documenting wound care. The STN reported she had been provided training

on 10/31/25 to monitor all residents with wounds review all resident's wound care orders and document all wound care provided. Certified Nurse's Aides #1 and 2 were interviewed and each confirmed they had been trained on 10/31/25 to observe all residents and note any new or old wounds and to document in each resident's EMR their observations and report to the assigned nurse, their observations of any changes in resident skin conditions. The facility nurse educator was interviewed and confirmed she had met with all nursing staff and trained them on 10/31/25 as to the requirements of the Plan of Removal.The facility administrator was interviewed and confirmed that the plan of removal had been reviewed by the facility Quality Assurance and Performance Improvement (QAPI) (a group of facility leaders who review the performance of the facility and staff and determine areas that could be improved) team on 10/22/25 and the changes were now included in the QAPI review.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/05/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Las Palomas Center

8100 Palomas Avenue NE Albuquerque, NM 87109

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0711 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

10/29/25 all care plans were audited and accurate per wound orders Starting on 10/31/2025 direct care staff were re-educated on Wound Documentation and inputting orders upon admission.Systemic Measures Starting 10/30/2025 the Center Nurses will be re-educated on the following areas by the Nurse Educator/Designee. Nurses will be re-educated on completion of skin assessments weekly per schedule.

Nurses will be educated on their responsibility with communication with management and provider for the change in condition process/documentation when a resident is having a change in condition (including new or worsening wounds). On 10/30/2025 Nurses will start to be educated on Genesis wound processes which include the DIMES, timely and accurate identification and documentation for wounds/wound changes, change in condition process, and appropriate treatment/intervention implementation upon identification of new or worsening wounds. CNA's will be educated on the change in condition process for CNA's (including skin changes) and stop and watch.As of 10/31/2025 100% of available staff have been educated on these processes. Any staff member that has not been scheduled, on leave of absence (FMLA), vacation, or PRN staff will be educated prior to returning to their next shift. Quality Assurance & MonitoringThe Director of Nursing/Designee will audit education sign-off sheets to ensure that all nursing staff receive the education mentioned above. The Director of Nursing/Designee will conduct 5 random audits of Residents that have wounds for skin assessment, order accuracy and for wound care process abidance. This will be audited weekly for 12 weeks.An Ad Hoc QAPI Meeting was held on 10/22/2025 to approve the above plan.The DON/designee and the Administrator/designee will bring the results of the audits to the QAPI committee for tracking, trending and further recommendations to ensure compliance with the plan. The audits will be brought to the QAPI committee for 3 months. The Administrator will oversee the QAPI committee.The Plan of Removal was approved on 11/04/25. The Immediate Jeopardy was removed as of 10/31/25 and the scope and severity was reduced from J to D.The POR was verified as follows:Record review confirmed full house audit of all residents to identify any wounds. On 11/05/25 at 11:00 am the Plan of Removal was verified when LPN #1, 2, 3 and Registered Nurse (RN) #1 each interviewed and stated they had been provided training on 10/31/25 which included reviewing all admitting orders for all residents, verifying the admitting orders with the facility provider and entering the admitting orders in each resident's EMR. All four nurses confirmed their training included monitoring all residents for daily wound care orders completing wound care orders and then documenting wound care. The STN reported she had been provided training

on 10/31/25 to monitor all residents with wounds review all resident's wound care orders and document all wound care provided. Certified Nurse's Aides #1 and 2 were interviewed and each confirmed they had been trained on 10/31/25 to observe all residents and note any new or old wounds and to document in each resident's EMR their observations and report to the assigned nurse, their observations of any changes in resident skin conditions. The facility nurse educator was interviewed and confirmed she had met with all nursing staff and trained them on 10/31/25 as to the requirements of the Plan of Removal.The facility administrator was interviewed and confirmed that the plan of removal had been reviewed by the facility Quality Assurance and Performance Improvement (QAPI) (a group of facility leaders who review the performance of the facility and staff and determine areas that could be improved) team on 10/22/25 and the changes were now included in the QAPI review.

Event ID:

Facility ID:

If continuation sheet