Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Paramount Convalescent Hosp. during CMS and state inspections, most recent first.
Infection Control Failures With EBP and Hand Hygiene: A resident with a chronic sacrococcyx pressure injury was observed without EBP signage or PPE during wound care, and an IP nurse was observed not performing hand hygiene before checking resident meal trays. The resident’s record documented DM, anemia, sick sinus syndrome, fluctuating decision-making capacity, and a physician order for daily wound treatment. Interviews confirmed the resident should have been on EBP and that hand hygiene should have been performed to prevent cross contamination.
Failure to Notify Ombudsman and Offer Bed Hold Notices During Hospital Transfers: The facility did not complete required bed hold notices or notify the LTC Ombudsman when several residents were transferred to the hospital. A resident with encephalopathy, CKD, DM, and chronic pulmonary edema had no bed hold form in the record, and staff confirmed the Ombudsman was not notified. Similar omissions occurred for other residents with diagnoses including DM, sick sinus syndrome, anemia, COPD, schizophrenia, and dementia; staff stated some residents were not offered bed hold notices and the Ombudsman was not notified of the transfers.
The facility failed to document COCs for three residents when antibiotics were started or present on admission. One resident had CKD, UTI, and CHF with orders for metronidazole and tetracycline; another had schizophrenia, HTN, and TBI with an azithromycin order; and a third had DM and HTN with an ertapenem order. The IPN and DON stated COC documentation should have been completed for antibiotic initiation. The facility also failed to review one resident’s hospital discharge records during the IDT admission meeting, despite staff stating admission documents and transfer information should be reviewed.
Two residents had antibiotic regimen issues. One resident with CKD, UTI, and CHF had metronidazole and tetracycline ordered for H. pylori prophylaxis without a stop date, and the IPN, DON, and PC all noted the lack of a stop date was a problem. Another resident with DM, sick sinus syndrome, and anemia received seven different antibiotic courses over several months for bacteremia, UTI, and other symptoms; the IPN said the repeated antibiotic use had not been discussed, and the DON said an IDT meeting should have been held to review the multiple antibiotics and avoid overprescribing.
Kitchen Hand Hygiene and Glove Change Deficiency During Tray Line: A dietary employee and a DA were observed switching between food service tasks during tray line without washing hands or changing gloves as required. The dietary employee moved from checking food temperatures to scooping beef, retrieved a dish from the dishwashing area, and opened drawers before returning to food prep without hand hygiene or glove changes. The DA changed gloves between tasks without washing hands while moving plated meals, filling hot water dispensers, and assisting with dessert; interviews confirmed staff should wash hands and change gloves when starting new tasks, and the facility policy required hand hygiene before donning gloves and after activities that may contaminate hands.
Failure to use McGeer's Criteria in the antibiotic stewardship program affected three residents. One resident received antibiotics for H. pylori prophylaxis, another received levofloxacin for UTI without progress note review to confirm clinical criteria, and a third received metronidazole and cephalexin without a documented McGeer's assessment. The IP and DON stated the required infection review and documentation were not completed or did not match the clinical indicators in the chart.
Failure to Notify Physician of Significant Weight Loss: A resident with atrial fibrillation, GERD, and dysphagia had a 17.9% weight loss after return from a GACH stay. RN and DON stated this was a significant weight loss and that nurses are expected to notify the physician, but the record showed no documentation that the physician was notified. The facility policy required notification of the resident, physician, and/or family member for significant changes in condition.
Failure to Monitor Behaviors for Resident on Antipsychotic Medication: A resident receiving aripiprazole for psychosis and angry outburst did not have target behaviors monitored or documented on multiple shifts. The behavior monitoring form lacked entries for several shifts, and the RN and DON confirmed that required every-shift monitoring was not completed, preventing assessment of the resident’s response to the medication and its effectiveness.
A resident with multiple UTIs, repeated antibiotic exposure, and a chronic sacrococcyx pressure injury had an EBP care plan with no goals or interventions, and the IDT did not develop a care plan for the resident's repeated infections and antibiotic use. Another resident's hospital discharge notes were not reviewed on admission, and the IDT did not reconcile the discharge instructions with the facility's antibiotic orders, despite the resident's impaired cognition and high risk for side effects and MDROs.
A resident with atrial fibrillation, GERD, and dysphagia experienced a 40-pound weight loss after GACH admission. The resident was not placed on weight variance, and the RD’s nutritional recommendations for a liberalized diet and Boost very high calorie were not included in the ICC. The DS and DON stated the resident should have been placed on weight variance and that the missed monitoring and ICC discussion placed the resident at risk for continued weight loss.
IPN failed to monitor a resident's ongoing antibiotic orders for H. pylori. The resident had CKD, CHF, UTI history, and moderately impaired cognition, and was ordered metronidazole and tetracycline via G-tube with no stop date entered. During interview, the IPN said she was unaware the resident had been receiving the antibiotics, did not think prophylactic antibiotics belonged in the antibiotic stewardship program, and admitted she did not consistently review hospital discharge records or follow the physician's stop-date instruction.
Expired enteral nutrition products were found in medication storage and central supply areas, including one expired Diabetes source container and seven expired Glucerna feeding source products. An RN stated she had checked the medication storage room earlier and did not see expired enteral feeding products, while the DON and MS said expired supplies should be identified and removed during routine checks. The facility policy stated expired items are to be immediately removed from stock.
Incomplete Consent to Treatment Documentation: A resident with COPD, HTN, and major depressive disorder had an incomplete consent to treatment form in the chart. The form was missing the resident’s date, the facility representative’s name, signature, and date. The resident stated he signed the consent and was informed about the risks and benefits, and the IP and DON confirmed the form was incomplete.
A resident with a history of stroke, hemiplegia, and hypertension experienced multiple episodes of elevated blood pressure over several months without timely assessment or physician notification by nursing staff, despite care plan and physician orders requiring such actions. The resident was eventually transferred to the hospital with hypertensive urgency after further increases in blood pressure and the onset of a headache. Staff interviews confirmed that required monitoring and notification procedures were not followed.
A resident with an indwelling urinary catheter was observed without a privacy bag covering the drainage bag, compromising their dignity and privacy. Despite facility policies requiring privacy bags, staff failed to apply one, leading to potential embarrassment for the resident. Staff interviews confirmed awareness of the requirement to maintain resident dignity by covering drainage bags.
The facility failed to provide adequate care for residents with limited ROM and mobility, specifically for three residents. For one resident, baseline ROM measurements were not obtained, and the resident's orthosis was not assessed for fit and wear tolerance, leading to ROM limitations and a contracture. Another resident did not receive baseline ROM measurements, and ROM changes were not monitored over ten months, placing the resident at risk for further limitations. Additionally, a resident's hips were not positioned at midline while lying in bed, potentially contributing to further ROM limitations.
The facility failed to follow infection control protocols, including not changing tube feeding bags every 24 hours, improper hand hygiene during wound care, and inadequate handling of soiled linens. Additionally, shared care equipment was not disinfected between uses, and the facility lacked a Legionella water management program.
The facility failed to maintain proper nail hygiene for two residents, leading to deficiencies in personal care. One resident with arthritis had unclean and long nails, despite care plans requiring regular maintenance. Another resident with dementia and diabetes was observed with dirty nails while eating, with no documentation of care refusal. Staff interviews revealed a lack of communication and adherence to nail care policies.
Two residents in an LTC facility experienced inadequate pressure ulcer care. One resident developed a Stage 1 pressure injury on the nose due to improper monitoring of a nasal cannula, while another with a Stage 4 ulcer was not repositioned effectively, leading to potential worsening of the condition. Staff interviews revealed communication lapses and failure to adhere to skin assessment protocols.
The facility failed to provide effective pain management for two residents. One resident with hypertension and headaches was not assessed or treated for pain in a timely manner, and another resident with cognitive impairments was not assessed for pain appropriately. The facility's policy on pain management, requiring the use of appropriate assessment tools based on cognitive status, was not followed, leading to deficiencies in care.
The facility failed to conduct annual competency evaluations for RNAs, affecting 13 residents receiving RNA services. In one case, a resident with limited ROM and mobility did not receive proper PROM exercises, and assistance was needed to apply an orthosis. Additionally, a RNS and LVN were not competent in taking a resident's blood pressure before administering Nitroglycerin, using an incorrect cuff size, which could lead to inaccurate readings and adverse reactions.
A LTC facility failed to maintain a medication error rate below five percent, with errors observed in two residents due to late administration of medications. A resident with complex medical conditions received multiple medications significantly later than prescribed, while another resident also experienced delays. The LVN responsible did not inform physicians of the delays, potentially affecting medication effectiveness. The DON confirmed the need for timely administration and physician notification.
The facility failed to maintain sanitary conditions in the kitchen, with unlabeled food items and improper hand hygiene observed. A cook did not wash hands or change gloves between tasks and failed to wear a beard net, risking cross-contamination. These actions violated the facility's policies on food safety and hygiene.
A resident with hemiplegia and hemiparesis did not receive prescribed PT, SLP, and OT services despite having physician-signed care plans. The resident required assistance for ADLs and had impairments in mobility and communication. Evaluations recommended specific therapies, but these were not implemented due to a verbal agreement among therapists to use restorative nursing aide services instead, contrary to the physician's certification.
The facility failed to ensure accurate documentation for two residents with mobility concerns, leading to false records of care provided. Additionally, a medication administration record inaccurately reflected medication given to a resident, as an LVN documented under another's name, violating facility policy.
A resident with cognitive impairments and multiple diagnoses was found with bilateral 1/2 siderails on their bed without a physician's order, contrary to the facility's restraint-free policy. Staff confirmed the siderails were used as restraints, posing risks of entrapment and injury, and no proper assessment or monitoring was conducted.
An LVN failed to maintain a resident's head of the bed at the required 30-degree angle during g-tube medication administration, contrary to facility policy. The resident, with a history of dementia and other health issues, was positioned incorrectly, risking aspiration. Interviews confirmed the policy and the LVN's acknowledgment of the error.
Two residents in an LTC facility experienced deficiencies in pain management due to the facility's failure to implement comprehensive care plans. One resident's pain monitoring was delayed despite a care plan, while another resident with a Stage 4 pressure ulcer had no pain management plan, leading to observable distress. Staff interviews confirmed these oversights, highlighting a failure to adhere to facility policies on care planning and pain management.
A resident with limited mobility and cognitive impairment was transferred using a mechanical lift by a single CNA, contrary to the care plan and facility policy requiring two staff members. This action increased the risk of accidents, as observed by the DON, who intervened to stop the transfer.
A resident with multiple mental health diagnoses was prescribed Alprazolam for anxiety without documented non-pharmacological interventions being attempted first. Facility staff, including an LVN and the RN Supervisor, confirmed that interventions like providing a calm environment or assessing for pain were not used before administering the medication. The facility's policy required such interventions to be attempted to avoid unnecessary psychotropic medication use.
A resident with end-stage renal disease and diabetes did not receive meals that accommodated her food preferences, despite dietary interventions in her care plan. The resident reported receiving unsuitable foods, and staff confirmed that her dislikes were communicated but not addressed. The facility's policy to obtain and note food preferences was not followed, risking decreased meal intake and weight loss.
A resident with legal blindness and intact cognitive function signed an arbitration agreement without proper explanation or assistance. Interviews revealed that the facility did not follow protocol, as the resident was not fully informed of the agreement's implications, and no witness was present during the signing.
The QAA Committee failed to implement corrective actions for RNA services, leading to repeated deficiencies in providing ROM and mobility services. A resident with hemiplegia received fewer AROM exercises than required, another did not consistently receive a palm guard or daily exercises, and a third resident with end-stage renal disease received PROM less frequently than needed. The DON confirmed the lack of evidence that these issues were addressed in QAA meetings.
A facility failed to maintain the wall in a resident's room, where a hole was observed in the drywall behind the bed. The Maintenance Supervisor confirmed the hole was not reported in the Maintenance Log, despite daily room rounds. The resident, with multiple health conditions, required assistance for daily activities. The facility's Preventative Maintenance Program policy was not followed, leading to the deficiency.
Infection Control Failures With EBP and Hand Hygiene
Penalty
Summary
The facility failed to implement proper infection control practices for residents with a chronic wound and during meal tray checks. During an observation in Resident 27’s room, there was no sign or PPE alert indicating Enhanced Barrier Precautions (EBP), and the treatment nurse was observed performing a wound care dressing change without wearing any personal protective equipment. Resident 27’s record showed diagnoses including DM, sick sinus syndrome, and anemia, and the physician order documented a sacrococcyx pressure injury treated with normal saline, collagen powder, calcium alginate, and a super absorbent dressing. The resident’s H&P noted fluctuating capacity to understand and make decisions, while the MDS indicated intact cognition and substantial/maximal assistance with ADLs. The facility also failed to ensure hand hygiene was performed before checking residents’ lunch meal trays. During an observation in the hallway near the dining room, the IP nurse was observed not washing her hands prior to checking the resident meal trays. In interviews, the TXN, IP nurse, and DON stated that Resident 27 should have been on EBP because of the chronic sacrococcyx wound, and the IP nurse and DON acknowledged that hand hygiene should have been performed before checking the meal trays to prevent cross contamination.
Failure to Notify Ombudsman and Offer Bed Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to ensure required discharge and transfer documentation was completed for multiple residents who were transferred to the GACH. Resident 3 was admitted with diagnoses including encephalopathy, CKD, type II DM, and chronic pulmonary edema, and the H&P stated the resident did not have the capacity to understand and make decisions. During record review and staff interviews, no bed hold form was found in the medical record for Resident 3 when the resident was transferred to the hospital for a low Hgb of 5.6 gm/dL, and staff stated the discharge nurse was responsible for completing the bed hold notice. The facility also failed to notify the LTC Ombudsman when Resident 3 was transferred. Staff interviews confirmed that the SSD was responsible for sending discharge notifications to the Ombudsman, but the SSD stated she overlooked notifying the Ombudsman when Resident 3 was discharged. The DON also stated the Ombudsman was not notified at the time of the transfer. The facility policy on Transfer and Discharge stated that when an immediate transfer or discharge is required by urgent medical needs, notice must be provided to the resident, the resident's representative if appropriate, and the LTC ombudsman as soon as practicable before transfer or discharge. Similar failures were identified for other residents transferred to the GACH. Resident 27 had diagnoses including DM, sick sinus syndrome, and anemia, with fluctuating capacity noted in the H&P and intact cognition on the MDS; the census showed transfer to the hospital and return to the facility, and the SSD stated the Ombudsman was not notified. Resident 29 had COPD and anemia, intact cognition, and substantial/maximal ADL assistance needs; the census showed multiple hospital transfers, and the SSD stated the Ombudsman was not notified of those transfers. Resident 51 had schizophrenia, dementia, and hyperlipidemia, with no capacity to understand and make decisions and severe cognitive impairment; staff stated no bed hold notice was offered when the resident was transferred to the GACH. The DON stated Resident 29 and Resident 51 were not offered bed hold notices and acknowledged the Ombudsman was not notified for Resident 27 and Resident 29.
Failure to Document Change of Condition and Review Admission Antibiotic Orders
Penalty
Summary
The facility failed to complete change-of-condition documentation for three sampled residents when antibiotics were initiated or present on admission. Resident 2 was admitted with chronic kidney disease, UTI, and CHF, had moderately impaired cognition and required maximal assistance with ADLs, and had orders for metronidazole 500 mg via G-tube every 8 hours and tetracycline 250 mg via G-tube every 12 hours for H. pylori prophylaxis. Resident 7 was admitted with schizophrenia, HTN, and TBI, had severely impaired cognition and was dependent with ADLs, and had an order for azithromycin 250 mg for a respiratory infection. Resident 13 was admitted with DM and HTN, had intact cognition and required maximal assistance with ADLs, and had an order for ertapenem sodium 1 gram for seven days. During a concurrent interview and record review, the Infection Prevention Nurse stated no COC documentation was completed for Resident 2, Resident 7, or Resident 13 in relation to their antibiotic therapy. The IPN stated COCs should be initiated when an antibiotic was ordered and when a resident was admitted to the facility on antibiotics so staff are monitoring the resident. The DON also stated a COC should be documented whenever an antibiotic was initiated for a resident, and that failure to document a COC could result in inadequate follow up and compromised resident care. The facility policy on Notification of Changes stated circumstances requiring a need to alter treatment include a new treatment. The facility also failed to review Resident 2's hospital discharge records during the admission IDT meeting. RNS 4 stated the IDT was responsible for reviewing all admission documents during the resident's admission meeting. The IPN stated there should have been an IDT meeting regarding Resident 2's antibiotics upon admission because the resident was at high risk for side effects and MDROs. The DON stated the IDT should have reviewed Resident 2's hospital discharge records to ensure the accuracy of medication orders and prevent potential medication errors, and the admission policy stated the process includes review of all available transfer information.
Unnecessary Antibiotic Use and Missing Stop Dates
Penalty
Summary
Unnecessary drug regimen management was identified for two sampled residents because the facility did not ensure antibiotic therapy was appropriately limited and monitored. Resident 2 was admitted with chronic kidney disease, UTI, and CHF, and the MDS showed moderately impaired cognition and need for maximal assistance with ADLs. On 10/11/2025, Resident 2 had orders for metronidazole 500 mg via gastrostomy tube every 8 hours and tetracycline 250 mg via gastrostomy tube every 12 hours for H. pylori prophylaxis, both with a stop date to follow. During interview, the IPN stated there was no stop date for either antibiotic and could not explain why one was needed, while the DON stated the orders should have had a stop date because long-term use could lead to kidney problems, MDROs, or C-diff. The PC also stated all antibiotic orders should have a stop date. Resident 27 was admitted with diabetes mellitus, sick sinus syndrome, and anemia. The H&P noted fluctuating capacity to understand and make decisions, while the MDS indicated intact cognition and substantial/maximal assistance with ADLs. The order listing showed seven antibiotic courses from 9/8/2025 through 12/1/2025, including daptomycin, ertapenem, meropenem, metronidazole, ceftriaxone, cephalexin, and Bactrim DS, each prescribed for different infections or symptoms such as bacteremia, UTI, and foul-smelling discharge. During concurrent interview and record review, the IPN stated Resident 27 had been on seven different antibiotics and that she had not discussed it with anyone in the facility, adding that she should have because the resident was at risk for overuse of antibiotics. The DON stated she was made aware that Resident 27 had been on seven different antibiotics since admission and said the resident should have had an IDT meeting to discuss the multiple antibiotic use to ensure the resident was not overprescribed antibiotics. The facility policy titled Antibiotic Stewardship Program stated all antibiotic prescriptions shall specify dose, duration, and indication for use, and that nursing staff should assess suspected infections, monitor response to antibiotics and lab results, and review antibiotic orders for appropriateness.
Kitchen Hand Hygiene and Glove Change Deficiency During Tray Line
Penalty
Summary
The facility failed to ensure infection control practices were followed in the kitchen during tray line operations. During an observation on 12/4/2025 at 11:32 a.m., the [NAME] was observed performing multiple food service tasks without washing hands or changing gloves between tasks. The [NAME] checked food temperatures and then scooped beef onto plates without hand hygiene or glove changes, walked to the dishwashing area to retrieve a dish and returned to the food preparation area without hand hygiene or glove changes, and opened drawers before immediately scooping food onto plates without hand hygiene or glove changes. During an observation on 12/4/2025 at 11:45 a.m., the Dietary Aid (DA) was observed switching tasks from transferring plated meals onto a food cart to filling hot water dispensers, and from placing food trays on the cart to assisting the Dietary Supervisor (DS) with dessert, while removing used gloves and putting on new gloves without washing hands. During interviews, the Cook, DA, and DS each stated that staff should wash hands and change gloves when switching tasks and before starting a new task. A review of the facility policy titled Handwashing Guidelines for Dietary Employees dated 12/19/2022 stated dietary employees shall clean their hands and exposed portions of their arms before donning gloves for working with food and after engaging in any activity that may contaminate the hands.
Failure to Use McGeer's Criteria in Antibiotic Stewardship
Penalty
Summary
The facility failed to follow its antibiotic stewardship program for three residents by not properly using McGeer's Criteria and by not reviewing antibiotic orders and related clinical documentation as required. The report states that the Infection Preventionist coordinated antibiotic stewardship activities and that the facility used CDC NHSN surveillance definitions and updated McGeer's criteria to define infections, but the required assessments were not completed or were not supported by the residents' documented symptoms and records. For one resident, the admission record showed diagnoses including chronic kidney disease, UTI, and CHF, and the MDS showed moderately impaired cognition and maximal assistance with ADLs. The resident was ordered metronidazole 500 mg every eight hours and tetracycline 250 mg every 12 hours for H. pylori prophylaxis after a hospital discharge note directed continuation of both antibiotics for 14 days. During interview, the IP stated that because the antibiotics were prescribed prophylactically, she did not believe they needed to be included in the facility's antibiotic stewardship program. The DON stated the IP should have assessed the appropriateness of the antibiotic regimen upon admission. For another resident, the admission record listed osteoarthritis, HTN, type II DM, and UTI, and the H&P noted fluctuating capacity to understand and make decisions. The MAR showed levofloxacin 500 mg daily for UTI for 7 days. During review, the IP stated she did not review the resident's progress notes to determine whether McGeer's criteria for UTI were met before completing the surveillance form, and that the documented symptoms did not match the required clinical indicators. The DON also reviewed the form and progress notes and stated the documented symptoms did not meet McGeer's criteria. For the third resident, the admission record listed DM, sick sinus syndrome, and anemia, and the H&P noted fluctuating capacity to understand and make decisions while the MDS showed intact cognition and substantial to maximal assistance with ADLs. The order listing report showed metronidazole 500 mg TID for five days for foul smelling discharge and cephalexin 500 mg TID for five days for UTI. The IP stated no McGeer's criteria assessment was found for either antibiotic course and that an assessment should have been completed to ensure the resident met criteria for a true infection before antibiotics were started. The DON stated the McGeer's Criteria should have been completed when the resident was started on metronidazole and cephalexin.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician of a significant weight loss for Resident 53 after readmission from a General Acute Care Hospital stay. Resident 53 was admitted to the facility on 9/23/2025 and later readmitted after a hospital stay from 10/6/2025 to 10/13/2025. The resident’s diagnoses included atrial fibrillation, GERD, and dysphagia. The H&P dated 11/7/2025 indicated the resident had the capacity to understand and make decisions, while the MDS dated 11/12/2025 indicated severely impaired cognition, dependence on staff for toileting and dressing, substantial assistance needed for eating, and a weight loss of 5% or more in the last month. The resident’s weight records showed a weight of 224 pounds on 10/1/2025 and 184 pounds on 10/14/2025, reflecting a 17.9% weight loss. During interviews, RN 3 and the DON both stated this was a significant weight loss and that nurses are expected to notify the physician of significant weight loss. Review of the nursing progress note dated 10/13/2025 showed no documentation that the physician was notified of the resident’s significant weight loss following discharge from the hospital. The facility policy on Notification of Changes stated the facility must inform the resident, consult with the physician, and/or notify the resident’s family member or legal representative when there is a significant change in condition.
Failure to Monitor Behaviors for Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to monitor target behaviors for one resident who was receiving aripiprazole 5 mg by mouth in the morning for psychosis and angry outburst. The resident was admitted with diagnoses including osteoarthritis, HTN, Type II DM, and UTI, and the H&P noted fluctuating capacity to understand and make decisions. The medication order was entered with a stop date, and the resident had a behavior monitoring form intended to document targeted behaviors while on the psychotropic medication. The behavior monitoring form showed that the resident was not monitored or documented during every shift on 11/13/2025, and there was no documentation for the morning and afternoon shifts on 11/14/2025. RN 4 reviewed the record and confirmed monitoring was not performed for the morning, afternoon, and evening shifts on 11/13/2025 and for the morning and afternoon shifts on 11/14/2025. The DON also reviewed the record and stated behavior monitoring should occur every shift when an antipsychotic medication is prescribed, and that without completed monitoring staff are unable to track changes in the resident's target behaviors or determine the effectiveness of aripiprazole.
Incomplete Care Planning and Admission Review
Penalty
Summary
Resident 27 had multiple diagnoses including DM, sick sinus syndrome, and anemia, and the record showed fluctuating capacity to understand and make decisions in the H&P, while the MDS indicated cognition was intact and that the resident required substantial to maximal assistance with ADLs. The physician orders showed treatment for bacteremia and repeated antibiotic courses for UTIs from September through November, including daptomycin, ertapenem, meropenem, metronidazole, ceftriaxone, cephalexin, and Bactrim DS. The Infection Preventionist reviewed the antibiotic use and stated the resident had been on six different antibiotics for UTIs and one for bacteremia. Resident 27 also had a sacrococcyx pressure injury with an order to clean with NS, apply collagen powder and calcium alginate, and cover with a super absorbent dressing daily. The care plan dated 9/24/2025 identified the resident as being on Enhanced Barrier Precautions related to a chronic wound, but there were no goals or interventions in place. During interview and record review, the Infection Preventionist stated the EBP care plan did not have goals or interventions and did not know why, and the DON stated all care plans need goals and interventions and that the facility should have had an IDT meeting to develop a plan of care for the resident's multiple UTIs and repeated antibiotic use. Resident 2 was admitted with CKD, UTI, and CHF, and the MDS showed moderately impaired cognition and maximal assistance with ADLs. The hospital discharge note instructed continuation of metronidazole and tetracycline for H. pylori treatment, but the facility's order details listed metronidazole and tetracycline as H. pylori prophylaxis. The RNS stated the IDT reviews all admission documents during the admission meeting but did not review the hospital discharge notes and said she should have; the IPN stated an IDT meeting should have occurred because of the resident's high risk for side effects and development of MDROs, and the DON stated the hospital discharge documents should have been reviewed upon admission for the resident's safety and care.
Failure to Monitor Significant Weight Loss and Include Nutritional Interventions in ICC
Penalty
Summary
The facility failed to consistently monitor Resident 53’s nutritional status after the resident experienced a significant weight loss. Resident 53 was admitted on 9/23/2025 and later readmitted with diagnoses including atrial fibrillation, GERD, and dysphagia. The H&P dated 11/7/2025 stated the resident had the capacity to understand and make decisions, while the MDS dated 11/12/2025 indicated severely impaired cognition, dependence on staff for toileting and dressing, substantial assistance needed for eating, and a weight loss of 5% or more in the last month. The weights and vitals summary showed the resident weighed 224 pounds on 10/1/2025 and 184 pounds on 10/14/2025, reflecting a 40-pound loss following GACH admission. During interview and record review, the Dietary Supervisor and DON stated Resident 53 was not placed on weight variance despite the significant weight loss and that this should have occurred per facility policy. The Nutritional Assessment recommended a liberalized diet and Boost very high calorie every day for 30 days, but those nutritional interventions were not included in the ICC dated 10/22/2025. The facility policy defined a significant weight change as a 5% change in weight in 1 month and stated documentation of significant weight changes shall be completed in accordance with facility policy and acceptable standards of practice.
IPN Failed to Monitor Ongoing Antibiotic Orders
Penalty
Summary
The facility failed to ensure the Infection Prevention Nurse (IPN) demonstrated competency in implementing infection control practices related to antibiotic usage for one resident. The resident was admitted with diagnoses including chronic kidney disease, UTI, and CHF, and the MDS dated 10/17/2025 indicated moderately impaired cognition and maximal assistance needed with ADLs. A GACH discharge note dated 10/6/2025 directed that metronidazole and tetracycline be continued for 14 days for treatment of H. pylori, with confirmation of eradication to be conducted at least four weeks after completion of the antibiotic regimen. On 10/11/2025, the resident had orders for metronidazole 500 mg via G-tube every eight hours and tetracycline 250 mg via G-tube every 12 hours for H. pylori prophylaxis, both with a stop date to follow. During interview on 12/4/2025, the IPN was unable to locate the resident's antibiotic orders and stated she was unaware the resident had been receiving antibiotics since 10/22/2025. She stated that because the antibiotics were prescribed prophylactically, she did not believe they needed to be included in the facility's antibiotic stewardship program, was unable to explain the potential impact of long-term antibiotic use, and acknowledged she did not follow the physician's order indicating stop date to follow or consistently review hospital discharge records upon admission.
Expired Enteral Nutrition Products Found in Medication Storage Areas
Penalty
Summary
The facility failed to ensure that expired enteral nutrition products were removed from the medication storage room after their expiration date. During an observation on 12/3/2025 at 2:17 p.m. in Medication Storage room [ROOM NUMBER], surveyors found one expired 1500 mL container of Diabetes source enteral nutrition formula in a red basket with an expiration date of 11/24/2025. During a concurrent observation and interview on 12/3/2025 at 2:45 p.m. in the central supply room, surveyors observed seven Glucerna feeding source products with an expiration date of 12/1/2025. RN 3 stated she had checked Medication Storage room [ROOM NUMBER] on 12/1/2025 and did not observe any expired enteral feeding products at that time. RN 3 stated expired feeding formula should be discarded promptly and should not be stored in medication storage areas. The DON and MS 1 both stated that expired supplies should be identified and removed during routine checks, and the facility policy stated outdated, contaminated, deteriorated, or expired medications are to be immediately removed from stock.
Incomplete Consent to Treatment Documentation
Penalty
Summary
The facility failed to ensure that consent to treatment documentation was completed with all required elements for one sampled resident. Resident 44 was admitted with diagnoses including COPD, HTN, and major depressive disorder. The resident’s H&P dated 8/16/2025 indicated that the resident had the capacity to understand and make decisions. During record review on 12/03/2025, the consent to treatment form in Resident 44’s chart was found to be missing the resident’s date, the facility representative’s name, signature, and date. During interview, Resident 44 stated he signed the consent to treatment and was informed about the risks and benefits for treatments. The IP and DON both reviewed the record and stated the consent to treatment was incomplete and missing the resident’s date, facility representative’s name, signature, and date. The facility’s policy titled Informed Consent, dated 12/19/2022, stated that when a form is used to document informed consent, licensed nursing staff will complete the Verification of Informed Consent Form and place it under the consent section in the clinical record.
Failure to Assess and Notify Physician for Elevated Blood Pressure
Penalty
Summary
The facility failed to assess a resident during multiple episodes of elevated blood pressure and did not notify the physician in a timely manner, as required by the resident's care plan and physician orders. The resident, who had a history of hemiplegia, cerebral infarction, atherosclerotic heart disease, and hypertension, was cognitively impaired and required varying levels of assistance with daily activities. Physician orders and care plans directed staff to monitor blood pressure regularly and notify the physician of significant abnormalities or changes in condition. Despite these directives, the resident experienced several documented episodes of systolic blood pressure above 150 mmHg over a period of months, with no evidence that staff assessed the change in condition or notified the physician as required. On the day of transfer to an acute care hospital, the resident had multiple high blood pressure readings and reported a headache, but staff did not notify the physician until after the condition had escalated. Upon arrival at the hospital, the resident was diagnosed with hypertensive urgency. Interviews with nursing staff and the DON confirmed that staff did not follow the care plan or facility policy regarding monitoring and physician notification for elevated blood pressure. Facility policies and job descriptions required staff to observe for changes in resident status, notify the physician and family, and document accordingly, but these procedures were not followed in this case.
Failure to Maintain Resident Dignity by Not Covering Catheter Bag
Penalty
Summary
The facility failed to ensure that a resident's indwelling urinary catheter drainage bag was covered with a privacy bag, compromising the resident's dignity and privacy. The resident, who was admitted with diagnoses including type 2 diabetes mellitus and urinary retention, had moderate cognitive impairment and required substantial assistance for toileting and showering. During an observation, it was noted that the resident's catheter drainage bag was not covered, which was confirmed by multiple staff members, including a CNA, LVN, and RNS, who acknowledged the importance of maintaining resident dignity by covering drainage bags. The facility's policy and procedure on catheter care, dated December 19, 2022, indicated that privacy bags should be available and used to cover catheter drainage bags at all times. Despite this policy, the staff failed to apply a privacy bag to the resident's drainage bag, leading to the potential for the resident to feel embarrassed and have low self-esteem. Interviews with the staff revealed that they were aware of the requirement to cover drainage bags to maintain resident dignity, yet the deficiency occurred, indicating a lapse in adherence to the facility's established procedures.
Failure to Provide Adequate ROM Care for Residents
Penalty
Summary
The facility failed to provide adequate care for residents with limited range of motion (ROM) and mobility, specifically for three residents. For Resident 43, the facility did not obtain baseline ROM measurements upon admission and during occupational therapy evaluation. The resident's left wrist hand orthosis was not assessed for fit and wear tolerance upon discharge from occupational therapy services. Additionally, the facility did not provide restorative nursing assistant services for passive range of motion exercises and the application of the orthosis for extended periods, leading to the development of ROM limitations and a contracture in the left hand. Resident 5 also did not receive baseline ROM measurements upon admission and during physical and occupational therapy evaluations. The facility failed to monitor ROM changes over a ten-month period, placing the resident at risk for further ROM limitations. The resident's care plan included interventions for passive range of motion exercises and the application of a palm guard, but these were not consistently implemented, as observed during interviews and record reviews. For Resident 18, the facility did not position the resident's hips at midline while lying in bed, which could contribute to further ROM limitations. The facility's failure to adhere to its policies and procedures for joint mobility screening and assessment, as well as the lack of consistent monitoring and implementation of recommended interventions, resulted in deficiencies in the care provided to these residents.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to infection control measures, resulting in several deficiencies. For instance, the facility did not ensure that tube feeding and water bags for two residents were changed every 24 hours, as confirmed by multiple staff members, including a Licensed Vocational Nurse, a Registered Nurse Supervisor, and the Director of Nursing. This oversight was acknowledged by the staff, who stated that the bags should be changed daily to prevent infection. In another instance, a Treatment Nurse failed to perform hand hygiene during wound care treatment for a resident with a Stage 4 pressure injury. The nurse changed gloves without washing hands between handling soiled dressings and applying medication, which was against the facility's policy. This was confirmed by the Infection Prevention Nurse and the Director of Nursing, who emphasized the importance of hand hygiene to prevent cross-contamination. Additionally, the facility did not handle dirty linens properly after providing personal care to a resident with ESBL, a resistant bacterial infection. A Certified Nursing Assistant was observed carrying soiled linens without placing them in a plastic bag, contrary to the facility's policy. The Infection Prevention Nurse confirmed that this practice could lead to cross-contamination. Furthermore, the facility lacked a Legionella water management program, which was acknowledged by the Maintenance Supervisor and the Administrator, indicating a potential risk for Legionella growth.
Deficiency in Nail Care for Residents
Penalty
Summary
The facility failed to ensure proper nail care for two residents, leading to deficiencies in personal hygiene and potential health risks. Resident 17, who suffers from Psoriatic Arthritis Mutilans and atrial fibrillation, was observed with unclean and long fingernails. Despite being unable to cut his own nails due to arthritis, the care plan for Resident 17 included interventions to maintain clean and short nails to prevent skin injuries and infection. However, observations and interviews revealed that the resident's nails were not properly maintained, and there was a lack of documentation indicating the need for nail trimming. Similarly, Resident 45, diagnosed with diabetes mellitus, unspecified dementia, and osteoporosis, was observed with long and dirty fingernails. The care plan for Resident 45 included regular nail care as part of daily living activities, but observations showed the resident eating with unclean nails, posing a risk of ingesting bacteria. Interviews with staff indicated a lack of communication and documentation regarding the resident's refusal of nail care, and there was no care plan addressing noncompliance or refusal of care. The facility's policy and procedure on nail care emphasized routine cleaning and inspection during daily living activities, yet these were not adequately followed for the two residents. The failure to maintain proper nail hygiene for Residents 17 and 45 was confirmed through observations, interviews, and record reviews, highlighting a deficiency in the facility's care practices.
Inadequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for two residents, leading to deficiencies in their treatment. Resident 39, who was admitted with conditions including aphasia, Alzheimer's disease, and a respiratory disorder, developed a Stage 1 pressure injury on the nose due to improper monitoring of the nasal cannula. Despite being dependent on staff for personal care and having a high risk for pressure injuries as indicated by a Braden Scale score of 11, the redness on the nasal septum was not reported or addressed in a timely manner. The CNA noticed the redness and applied ointment but did not effectively communicate this to the LVN, who failed to conduct the necessary skin checks. Resident 18, who had a Stage 4 pressure ulcer on the sacrococcyx area and contractures in both knees, was not repositioned adequately to offload pressure from the affected area. Despite having a care plan that included interventions to prevent further skin breakdown, the resident was often found lying on his back, which could exacerbate the pressure injury. The staff struggled to reposition the resident due to his contractures and frequent movements, and the use of pillows for repositioning was ineffective as the resident often removed them. Interviews with staff revealed a lack of communication and adherence to protocols for monitoring and reporting skin conditions. The facility's policy required regular skin assessments and immediate reporting of any concerns, but these were not consistently followed. The DON acknowledged that improper repositioning and ineffective interventions could lead to worsening pressure injuries, highlighting the need for better monitoring and assessment practices.
Inadequate Pain Management for Residents with Cognitive Impairments
Penalty
Summary
The facility failed to provide effective pain management for two residents, leading to deficiencies in care. Resident 11, who was admitted with hypertension and headaches, was not assessed or treated for pain in a timely manner. Despite having a care plan that required pain monitoring every four hours, this was not initiated until a day after the plan was updated. On one occasion, Resident 11 reported having a headache since the morning and had not received his scheduled medication. The LVN responsible for administering the medication admitted to not doing so because Resident 11 was sometimes difficult, and he forgot to ask another nurse to assist. This oversight was acknowledged by the RN Supervisor and the DON, who emphasized the importance of pain assessment, especially given Resident 11's hypertension, which could lead to serious complications like a stroke. Resident 18, who had multiple diagnoses including a stage 4 pressure ulcer and cognitive impairments, was also not assessed for pain appropriately. The resident's cognitive impairments made it difficult for them to communicate pain levels effectively using a numerical pain rating scale. Despite this, the LVN used this method to assess pain, which was not suitable given the resident's condition. During a wound dressing change, Resident 18 exhibited nonverbal signs of pain such as moaning and grimacing, which were not adequately considered in the pain assessment. Both the RN Supervisor and the DON acknowledged that nonverbal signs should have been used to assess pain due to the resident's cognitive limitations. The facility's policy on pain management, which requires the use of appropriate pain assessment tools based on a resident's cognitive status, was not followed. This resulted in inadequate pain management for Resident 18, as the staff did not use nonverbal indicators to assess pain. The failure to adhere to the policy and properly assess pain in residents with cognitive impairments led to deficiencies in the care provided to both Resident 11 and Resident 18.
Deficiencies in Staff Competency Evaluations and Blood Pressure Monitoring
Penalty
Summary
The facility failed to ensure that five Restorative Nursing Assistants (RNAs) had their annual competency evaluations for providing range of motion (ROM) exercises, application of orthotics, and ambulation to 13 residents receiving RNA services. This deficiency was observed during an interview with the Director of Rehabilitation, who confirmed that the purpose of the RNA program was to maintain residents' function and prevent decline in mobility. The competency evaluations for the RNAs were last completed in May 2023, and should have been completed again in May 2024, but were not. This lapse in competency evaluations had the potential to affect the quality of care provided to residents, including Resident 43, who had limited ROM and mobility due to conditions such as end-stage renal disease and hemiplegia. In a specific incident, Resident 43 was observed receiving RNA services, where RNA 1 and RNA 2 performed exercises on the resident's limbs. However, RNA 2 was unable to fully extend the resident's left-hand fingers and required assistance to apply a left wrist-hand orthosis. RNA 2 also forgot to perform PROM exercises on the resident's left elbow. This incident highlighted the lack of competency in performing necessary tasks, which could lead to a decline in the resident's ROM and mobility. Additionally, the facility failed to ensure that a Registered Nurse Supervisor (RNS) and a Licensed Vocational Nurse (LVN) were competent in taking a resident's blood pressure before administering Nitroglycerin. Resident 27, who had conditions such as morbid obesity and congestive heart failure, complained of chest pain, and the RNS used an incorrect blood pressure cuff on the forearm instead of the upper arm. This could have resulted in an inaccurate blood pressure reading, potentially leading to adverse reactions with the medication. The facility's policy indicated that staff should have the appropriate competencies to ensure resident safety, which was not adhered to in this case.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by eleven medication errors out of thirty-three opportunities, resulting in a 33.33 percent error rate. This deficiency was observed in two of the four sampled residents, specifically Residents 28 and 37. The errors were primarily due to the late administration of medications, which were not given within the facility's protocol time frame of one hour before or after the scheduled time. Resident 28, who has a complex medical history including acute and chronic respiratory failure, pulmonary hypertension, hypertensive heart disease, epilepsy, diabetes mellitus type 2, diabetic neuropathy, and dementia, received multiple medications significantly later than the prescribed time. Medications such as Amiodarone, Apixaban, Budesonide, Levetiracetam, Pregabalin, and Sildenafil were administered well past the scheduled 9:00 a.m. time, with some given as late as 2:16 p.m. Similarly, Resident 37, with diagnoses including hypertensive heart disease, cerebral infarction, and depression, also received medications like Finasteride, Gabapentin, and Hydralazine later than scheduled. The Licensed Vocational Nurse (LVN) responsible for administering these medications acknowledged the delay and stated that the facility protocol allows for a two-hour window for medication administration. However, the LVN did not inform the residents' physicians of the delays, which could potentially affect the therapeutic effectiveness of the medications. The Director of Nursing confirmed that the medications should have been administered within the specified time frame and that the physicians should have been notified of any delays to ensure proper treatment outcomes.
Sanitation and Hygiene Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed during a survey. Several food items, including an open bag of peanut butter dough, frozen fries, and bottles of salsa, were found without proper labeling and dating, which is essential to prevent foodborne illnesses. Interviews with kitchen staff confirmed that these items should have been labeled with the date they were opened and a use-by date, as per the facility's policy. This oversight was acknowledged by the staff, who recognized the importance of labeling to ensure food safety. Additionally, a cook was observed not practicing proper hand hygiene during food preparation and distribution. The cook did not wash hands or change gloves between tasks, such as cooking, checking food temperatures, and plating meals, which is a critical step in preventing cross-contamination. Furthermore, the cook did not wear a beard net while handling food, despite having facial hair, which could lead to contamination. These practices were contrary to the facility's policies on handwashing, glove use, and personal hygiene, which are designed to maintain a safe and sanitary environment.
Failure to Provide Required Therapy Services
Penalty
Summary
The facility failed to provide necessary therapy services to a resident with significant mobility and communication concerns, as outlined in the resident's physician-signed care plans. The resident, who had been diagnosed with hemiplegia and hemiparesis following a cerebral infarction, was admitted with functional range of motion limitations and required various levels of assistance for activities of daily living. Despite having care plans for physical therapy (PT), speech therapy (SLP), and occupational therapy (OT) that were signed and certified by the resident's physician, these services were not implemented. The PT evaluation indicated that the resident had impaired range of motion in both ankles and required therapeutic exercises, neuromuscular reeducation, and other interventions three times per week for four weeks. Similarly, the SLP evaluation identified mild to moderate oral dysphagia, necessitating treatment twice a week for four weeks. The OT evaluation noted impairments in the right shoulder, wrist, and hand, with a contracture in the right hand, and recommended therapy three times per week for one week. Despite these evaluations and plans, the therapies were not provided, and the resident did not receive any interventions to improve communication, mobility, or activities of daily living. Interviews with the Director of Rehabilitation and the Director of Nursing revealed that the resident's therapy plans were not implemented because the resident was considered totally dependent for mobility and ADLs. Instead, there was a verbal agreement among the therapists that the resident would benefit more from restorative nursing aide services rather than therapy. This decision was made despite the physician's certification of the need for therapy services, and the facility's policy aimed at restoring residents to their highest level of function.
Inaccurate Documentation and Medication Administration Errors
Penalty
Summary
The facility failed to ensure accurate documentation for two residents with limited range of motion and mobility concerns. For one resident, the documentation inaccurately recorded that a Restorative Nursing Assistant (RNA) provided passive range of motion (PROM) exercises and applied a wrist-hand orthosis (WHO) on a day when the RNA was on vacation and not present at the facility. Observations and interviews revealed that the resident did not receive the prescribed exercises and orthosis application as documented, indicating false and inaccurate record-keeping. Another resident's documentation inaccurately reflected that an RNA provided active range of motion (AROM) exercises to both legs on specific dates. However, interviews revealed that the RNA did not perform these exercises due to a past conflict with the resident, and the documentation was completed by the RNA without providing the services. This led to inaccuracies in the resident's clinical records, as the actual services provided were not documented by the RNAs who performed them. Additionally, the facility failed to ensure that a medication administration record (MAR) accurately reflected the administration of medication to a resident. A Licensed Vocational Nurse (LVN) documented under another LVN's name, leading to potential liability issues and inaccuracies in the resident's medical records. The facility's policy requires that the individual who administers medication records the administration directly after the medication is given, which was not followed in this instance.
Improper Use of Physical Restraints on a Resident
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, as evidenced by the use of bilateral 1/2 siderails on the resident's bed without a physician's order or assessment. The resident, who was admitted with diagnoses including major depressive disorder, bipolar disorder, schizoaffective disorder, and contracture of both knees, was observed with siderails that were not ordered by a physician. The resident's cognitive skills were moderately impaired, requiring substantial assistance with daily activities, and the use of these siderails was not in compliance with the physician's order for 1/4 assist devices. Observations revealed that the resident was lying in bed with both 1/2 siderails up, which was confirmed by the RN Supervisor as being against the physician's order. Interviews with staff, including a CNA, LVN, and the DON, indicated that the use of these siderails was considered a form of restraint, as they restricted the resident's movement and could lead to potential risks such as skin tears, fractures, or entrapment. The facility's policy on a restraint-free environment was not adhered to, as there was no monitoring or assessment for the use of these siderails. The facility's policy and procedure emphasized the prohibition of restraints for discipline or convenience, and required behavioral interventions to be exhausted before applying physical restraints. However, the use of bilateral 1/2 siderails without proper authorization and assessment demonstrated a failure to comply with these guidelines, placing the resident at risk for unnecessary restraint and associated complications.
Improper Positioning During G-Tube Medication Administration
Penalty
Summary
Licensed Vocational Nurse (LVN) 4 failed to maintain the head of the bed for Resident 38 at a minimum of 30 degrees during the administration of medications through a gastrostomy tube (g-tube), as per the facility's policy and procedure. This failure was observed during an incident where LVN 4 checked the g-tube for placement and residual while Resident 38 was lying on her right side at a 20-degree angle. LVN 4 then began administering medications without re-checking the g-tube placement or residual after repositioning Resident 38 to a 75-degree angle on her back. Resident 38 had a medical history that included a gastrostomy tube for feeding, hypertensive heart disease, depression, diabetes mellitus type 2, and dementia. The resident was noted to have impaired cognitive skills and was unable to make decisions for herself. The facility's policy required the head of the bed to be elevated at a minimum of 30 degrees during feeding or medication administration to prevent aspiration and pneumonia. Interviews with LVN 4, the Director of Staff Development (DSD), and the Director of Nursing (DON) confirmed the facility's policy and the importance of proper positioning to prevent aspiration pneumonia. LVN 4 admitted to positioning Resident 38 incorrectly to save time, acknowledging the risk of aspiration and potential fatality. The facility's policy and procedure documents reiterated the need for proper positioning during enteral feeding and medication administration.
Deficiencies in Pain Management for Two Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-focused care plan for two residents, leading to deficiencies in pain management. Resident 11 was admitted with diagnoses including hypertension and headaches. A care plan was initiated on October 2, 2024, focusing on managing Resident 11's constant pain with an intervention to monitor pain every four hours. However, documentation showed that pain monitoring did not begin until October 3, 2024, at 4:00 p.m., indicating a delay in implementing the care plan. Interviews with staff confirmed that the care plan was not followed as required, placing Resident 11 at risk for delayed care and treatment. Resident 18, who was readmitted with multiple diagnoses including a Stage 4 pressure ulcer, major depressive disorder, and cognitive impairments, did not have a care plan addressing pain despite observable signs of distress during wound dressing changes. The resident was observed moaning and grimacing, yet no care plan was in place to manage the pain associated with the pressure ulcer. Interviews with nursing staff revealed that a care plan for pain was only initiated after the surveyor began investigating the issue, highlighting a significant oversight in addressing the resident's pain management needs. The facility's policies and procedures require the development of a comprehensive care plan within seven days of completing the Minimum Data Set assessment, including measurable objectives and timeframes to meet residents' needs. Additionally, the facility's pain management policy emphasizes the importance of managing pain in accordance with the comprehensive assessment and plan of care. The failure to adhere to these policies resulted in inadequate pain management for both residents, as evidenced by the lack of timely interventions and documentation.
Inadequate Supervision During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure adequate supervision and adherence to safety protocols during the transfer of a resident with limited range of motion and mobility. Resident 18, who has diagnoses including parkinsonism, autistic disorder, and contractures of both knees, was observed being transferred by a single Certified Nursing Assistant (CNA) using a mechanical lift, despite the care plan and facility policy requiring two staff members for such transfers. This action was observed during a transfer from the bed to the shower bed, placing the resident at increased risk for accidents, including potential falls and physical injury. The deficiency was identified during an observation where CNA 10 was seen operating the mechanical lift alone, contrary to the facility's policy and the resident's care plan, which both mandate two-person assistance for mechanical lift transfers. The Director of Nursing (DON) intervened during the observation, instructing CNA 10 to halt the transfer and wait for additional assistance. CNA 10 later acknowledged the requirement for two-person assistance but cited the unavailability of other staff as the reason for proceeding alone. The facility's policy on Safe Resident Handling/Transfers, revised earlier in the year, clearly states the necessity of two staff members for mechanical lift transfers to ensure resident safety and minimize injury risk.
Failure to Implement Non-Pharmacological Interventions Before Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 18, was free from unnecessary medication by not implementing non-pharmacological interventions before administering psychotropic medication. Resident 18, who was diagnosed with major depressive disorder, bipolar disorder, schizoaffective disorder, and autistic disorder, was prescribed Alprazolam for anxiety manifested by an inability to relax. However, there was no documentation of non-pharmacological interventions being attempted prior to the administration of Alprazolam, which could lead to unnecessary use of psychotropic medication. Interviews with facility staff, including an LVN and the RN Supervisor, revealed that non-pharmacological interventions such as offering food, repositioning, providing a calm environment, listening to music, and assessing for pain were not utilized before administering Alprazolam. The RN Supervisor and the Director of Nursing acknowledged that the behavior described as 'inability to relax' was too general and not specific enough to warrant the use of Alprazolam. The facility's policy required that non-pharmacological interventions be attempted to facilitate the reduction or discontinuation of psychotropic drugs, and that PRN orders for such medications should only be used when necessary for a diagnosed specific condition with documented rationale.
Failure to Accommodate Resident's Food Preferences
Penalty
Summary
The facility failed to provide meals that accommodated the food preferences of a resident with end-stage renal disease, diabetes mellitus, and dependence on renal dialysis. The resident, who had fluctuating capacity to understand and make decisions, was dependent on staff for various activities of daily living. The care plan for the resident included dietary interventions to regulate protein and potassium intake and to follow up with the resident's food preferences. However, the meal tray card for the resident did not indicate any food preferences or dislikes, and the resident reported receiving foods like potatoes, yams, and cheese, which were not suitable for her kidney condition. Interviews with staff revealed that the resident's dislike for certain foods, such as cheese on scrambled eggs, was communicated to the dietary manager, but no action was taken to address these preferences. The dietary manager confirmed that nutritional assessments are conducted upon admission and as needed, but was unaware of the resident's dislike for cheese. The facility's policy required obtaining food preferences and noting them in the dietary records, but this was not followed, leading to the potential for decreased meal intake and weight loss for the resident.
Failure to Ensure Resident Understanding of Arbitration Agreement
Penalty
Summary
The facility failed to ensure that a resident was fully informed and aware of the implications of signing a binding arbitration agreement. The resident, who was legally blind and had a diagnosis of Diabetes Mellitus, was admitted to the facility and signed the arbitration agreement. However, during an interview, the resident stated that she could not recall signing the agreement or having it explained to her. She also mentioned that she would not have signed such an agreement if she had understood its nature. The resident's cognitive function was assessed as intact, but her visual impairment required assistance for signing documents, which was not adequately provided. Interviews with the Admissions Coordinator and the Director of Nursing revealed that the proper protocol was not followed when the resident signed the arbitration agreement. The Admissions Coordinator, who was not employed at the facility at the time, stated that a witness should have been present due to the resident's blindness. The Director of Nursing confirmed that the resident should not have been asked to sign the agreement without a family member or representative present, as it compromised her rights. The facility's policy required that residents or their representatives acknowledge understanding the agreement, which was not ensured in this case.
Failure to Implement Corrective Actions for RNA Services
Penalty
Summary
The Quality Assessment Assurance (QAA) Committee at the facility failed to implement corrective actions from a previous re-certification survey concerning the Restorative Nursing Aide (RNA) services. This failure resulted in repeated deficiencies related to the provision of range of motion (ROM) and mobility services. Specifically, the facility did not ensure that passive range of motion (PROM) exercises and splint applications were consistently provided to residents as per their care plans. For instance, Resident 32, who was admitted with hemiplegia and hemiparesis, was supposed to receive active range of motion (AROM) exercises five times a week but reported receiving them only twice a week. Similarly, Resident 5, with similar diagnoses, was not consistently provided with a palm guard or daily exercises as required by their care plan. Resident 43, who had end-stage renal disease and hemiplegia, was supposed to receive PROM and have a wrist hand orthosis applied five times a week but reported receiving exercises only once a week. The Director of Nursing (DON) confirmed the lack of evidence that these deficiencies were addressed in QAA meetings, indicating a systemic issue in addressing and correcting the RNA service deficiencies.
Facility Failed to Maintain Wall Integrity in Resident's Room
Penalty
Summary
The facility failed to maintain the wall in one of its rooms, specifically Room A, where a hole was observed in the drywall behind a resident's bed. This deficiency was identified during observations and interviews conducted over several days. The Maintenance Supervisor confirmed that the hole was not reported in the facility's Maintenance Log, despite daily room rounds being performed by the maintenance staff. The presence of the hole posed potential hazards, including the risk of water, fire, and pest intrusion into the resident's room. The resident involved, identified as Resident 27, was admitted with multiple health conditions, including morbid obesity, hypertensive heart disease, congestive heart failure, type 2 diabetes mellitus, and reduced mobility. The resident required varying levels of assistance for daily activities and was found lying awake in bed during the observation. The facility's Preventative Maintenance Program policy indicated that the Maintenance Director was responsible for ensuring the safety and operability of the building, but the hole in the drywall was not addressed, leading to the deficiency.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Paramount
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| La Paz Geropsychiatric Center | 1 mi | ★★★★★ | 33 | 0 |
| Downey Post Acute | 1.2 mi | ★★★★★ | 20 | 0 |
| Meadow Creek Post-acute | 2 mi | ★★★★★ | 16 | 0 |
| Lakewood Healthcare Center | 2 mi | ★★★★★ | 45 | 0 |
| Sunset Villa Post Acute | 2.1 mi | ★★★★★ | 26 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.