Palomino Place

In the surveyor’s words

From the most serious findings on record at Palomino Place, in the surveyor’s own words.

• Immediate jeopardy, isolatedF755Aug 27, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF760Jun 27, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF689Feb 13, 2024

  Based 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. […]

• Actual harm, patternF686Jul 30, 2025

  Based 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. […]

• Actual harm, isolatedF600May 22, 2026

  Based 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.Findings include: Review of Resident #1's Quarterly MDS Assessment, dated 04/15/2026, reflected an [AGE] year-old female admitted to the facility on [DATE]. She had a BIMS score of 10 which indicated moderate cognitive impairment. […]