La Paloma Healthcare Center

In the surveyor’s words

From the most serious findings on record at La Paloma Healthcare Center, in the surveyor’s own words.

• Actual harm, isolatedF689Jul 9, 2021

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Jun 18, 2026

  Based on observation, interview, and record review, the facility failed to ensure the kitchen environment and food handling processes were maintained in a sanitary manner in accordance with accepted standards of practice when:Dishware was stored wet, pitcher lids were cracked and broken, and grime was on the freezer doors and gasket.Cook 1 used a potentially contaminated glove to touch bread rolls. In addition, dietary staff did not take the final temperature of all food to be served during lunch.Dietary Aid (DA) 1 and DA 2 were not wearing beard guards while in the kitchen.Six bottles of grape supplemental protein 30 fluid ounces, three bags of renal tube feeding (formulated food delivered through a feeding tube) formula, and six bottles of carbohydrate-controlled tube feeding formula… […]

• No harm, potential for more than minimal, patternF578Jun 18, 2026

  Based on interview and record review the facility failed to ensure a resident's right to formulate an advance directive (a legal document that outlines your preferences for medical care and treatments if you become incapacitated and unable to communicate) for four out of seven sampled residents (Residents 8, 50, 86, and 92). This failure to communicate advance directive information could have resulted in care being provided that was inconsistent with the resident's expressed healthcare wishes.Findings: A review of Resident 8's admission Record indicated Resident 8 was admitted to the facility on [DATE] with a diagnosis that included hemiplegia (complete paralysis of one side of the body) and hemiparesis (weakness or partial paralysis on one side of the body) following cerebral infarction. […]

• No harm, potential for more than minimal, patternF757Jun 18, 2026

  Based on interview and record review, the facility failed to ensure one of five residents, (Resident 2) was free from unnecessary medication when the resident was administered oxycodone (a controlled pain medication) doses for severe pain five times in June 2026 when the resident's pain assessment indicated the resident had no pain or had minimal pain. This deficient practice had the potential for Resident 2 to develop side effects, tolerance and addiction.Findings: A review of Resident 2's admission Record indicated the resident was admitted on [DATE] with diagnoses to include toxic encephalopathy (disease that alters the brain function), right femur fracture and alcoholic cirrhosis. A review of Resident 2's Order Summary Report dated 6/15/26, indicated two orders for oxycodone: 1. […]

• No harm, potential for more than minimal, patternF686Jul 9, 2021

  Based 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. Findings: 1. Per the facility's Resident Face Sheet, Resident 24 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Per Resident 24's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Set mode at alternating, per weight or residents comfort . On 7/7/21 at 8:41 A.M., a concurrent observation and interview was conducted with Resident 24. Resident 24 was lying on an LAL mattress, which was set to 140. […]