Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Paradigm At Faith Memorial during CMS and state inspections, most recent first.
Care plan not revised for skin condition. A resident with COPD, DM, heart disease with HF, ataxic gait, and muscle weakness had weekly skin checks and a skin eval showing intact skin with no wounds or pressure areas, yet the care plan still listed a non-pressure/surgical skin condition with wound-related interventions. The resident, an LVN, the wound care nurse, the MDS nurse, and the DON all stated the resident did not currently have a skin condition and that the care plan needed revision.
Expired medications were found in the Station 1 med fridge, including a Prochlorperazine suppository and Acetaminophen suppositories past their expiration dates. The DON said expired meds should be removed, but night nurses were mainly checking the fridge temperature log and did not normally check all meds for expiration. RN A stated she usually verified temperature only, while the Consultant Pharmacist said expired meds should not remain in the fridge and the facility policy required outdated meds to be destroyed or returned to the pharmacy.
A resident with severe dementia, PTSD, and a history of behavioral episodes became agitated during a noisy overnight shift when fireworks and gunshots in the neighborhood disturbed multiple residents. A CNA later reported to another CNA that the resident had approached the nurse’s station and raised a hand as if to hit, and that the CNA responded by cursing at the resident and threatening to "show" the resident if struck. The second CNA did not immediately report this allegation of verbal abuse despite regular ANE training and only disclosed it later in response to a DON inquiry. The facility did not report this abuse allegation to the state survey agency within the required 5-working-day timeframe, resulting in a deficiency for failure to timely report suspected abuse.
A resident with serious mental illness, moderate cognitive impairment, bowel incontinence, and documented feces-smearing behavior experienced multiple episodes where feces were on his hands, under his fingernails, on his face, beard, sides of his mouth, teeth, and pillow, and in or around his mouth. A medication aide/CNA saw the resident reach into his brief, pull out feces, and attempt to put his soiled hand into his mouth, cleaned him, but did not document or report the incident. A PTA observed the resident with feces on his hands, facial hair, and in his teeth, cleaned his hands, and verbally informed an LVN and the rehab director, but there was no clear documentation or escalation to nursing leadership. An anonymous report stated an LVN entered the room after being told the resident had feces on his hand, refused to address the situation, and left, while another staff member partially cleaned the resident. Nursing leadership and the resident’s primary nurse reported they were not informed of these behaviors at the time, despite an existing care plan for feces smearing and a facility infection control policy requiring surveillance, reporting, and QAPI oversight, resulting in a cited failure to maintain an effective infection prevention and control program.
A resident with severe dementia, PTSD, and a history of behavioral episodes lived on a secure unit and was highly sensitive to loud noises and perceived threats. During a period of increased agitation related to neighborhood fireworks and gunshots, a CNA reported that the resident came around the nurse’s station and tried to hit her, and in response she cursed at and threatened the resident using profane language. Another CNA later confirmed that this statement was made but did not immediately report it. Bruising was subsequently observed on the resident’s right hand and forearm by nursing staff, and a CNA acknowledged having seen the bruising earlier but assumed it was old and did not notify a nurse at that time. These actions and inactions, in the context of existing behavior-management and combative-resident policies and ongoing ANE training, resulted in a deficiency for failure to ensure the resident was free from verbal abuse and for delayed reporting of an observed injury and abuse allegation.
A resident with serious mental illness, moderate cognitive impairment, incontinence, and diarrhea exhibited repeated behaviors of reaching into a soiled brief and ending up with feces on the hands, under the fingernails, on the beard and around the mouth, and in the mouth and teeth. Multiple staff, including a medication aide, LVNs, and therapy staff, observed these episodes, but incidents were often not reported to the charge nurse or DON, not consistently documented as a change in condition, and not communicated to the physician or family. The existing care plan addressed PASRR-positive mental illness and later referenced feces smearing but did not specifically include the behavior of digging into the brief and contaminating the mouth, nor did it contain detailed, measurable interventions and monitoring for this behavior. This resulted in the resident’s recurrent feces-related behaviors not being comprehensively assessed and incorporated into a person-centered care plan consistent with the resident’s medical, nursing, mental, and psychosocial needs.
A resident with schizoaffective disorder, bipolar disorder, and moderate cognitive impairment, who was incontinent and PASRR Level II, repeatedly dug into a soiled brief and ended up with feces on the hands, under the fingernails, on the face and beard, and in the mouth and teeth. Multiple staff, including a medication aide, an LVN, and a PTA, observed separate episodes where the resident attempted to put a feces-soiled hand into the mouth or was found with feces on the hands and around the mouth, yet these incidents were not consistently documented, reported to the charge nurse, DON, or MD, and were not reflected as specific behaviors in the care plan. The resident’s primary nurse reported she had not been informed of these behaviors and would have treated them as a change in condition requiring MD notification, while leadership confirmed they were unaware of any MD notification regarding feces in or on the resident’s mouth, despite facility policies requiring prompt reporting of condition changes and adherence to infection control and standards of care.
A resident who had left the facility with family was documented as having received multiple medications on several dates after their departure. Staff interviews confirmed the resident did not return, yet medication aides continued to record medication administration in the electronic medical record. The facility's policy required staff to flag the MAR and follow guidelines when a resident was not present, but this was not followed, resulting in inaccurate medical records.
Two residents with indwelling urinary catheters did not receive catheter changes as ordered and per facility expectations, and documentation of catheter changes was absent over multiple months. One resident’s catheter bag showed an installation date several weeks prior, with brown discoloration and odor, and the resident reported anxiety about the lack of catheter changes. Another resident with a suprapubic catheter had an order for monthly changes, but observations showed the same bag in place for an extended period, and this resident was later treated with oral antibiotics for a UTI. Nursing leadership stated that nurses were responsible for changing catheters every 30 days and as needed, and that such changes should be documented on the MAR/TAR, which did not occur in these cases.
A resident with paraplegia, moderate cognitive impairment, and chronic lower back pain had an order for Acetaminophen-Codeine 300-30 mg every 8 hours, but MAR reviews over several months showed multiple doses marked with a code indicating "Other/See Progress Notes" without corresponding documentation that the medication was given. The resident reported that this occurred repeatedly, that staff told her the medication was not available and blamed the pharmacy, and that she experienced significant pain and inability to sleep when she did not receive her pain medication. A medication aide stated she would document code 8 when the narcotic was not available and she had notified a nurse, while nursing staff and the ADON described processes for reordering narcotics and use of the automated dispensing system but could not explain the specific missed or undocumented doses, despite facility policy requiring medications to be administered as prescribed.
A resident with vascular dementia eloped from a facility due to inadequate supervision and an unsecured side door. The resident, who was severely cognitively impaired, was missing for about an hour before being found by police. The facility failed to conduct an elopement risk assessment upon admission, and staff did not notice the resident was missing until informed by a family member.
The facility failed to maintain the required RN coverage of eight consecutive hours per day, seven days a week, on four occasions in September 2024. Interviews and record reviews revealed that RNs did not work the necessary hours, and there were incidents of falls and aggression on some of these days. The DON and Administrator were not aware of the issue due to their recent employment, and changes in human resources personnel may have contributed to the oversight.
The facility failed to transmit MDS data to the CMS System within 14 days for two residents, leading to potential delays in care plans and payment issues. The MDS coordinator cited waiting for RN signatures and staff turnover as reasons for the delay.
A resident with severe cognitive impairment and multiple health conditions complained of tooth pain and difficulty chewing, but the facility failed to refer her to a dentist. Despite the resident's care plan indicating dental concerns, staff did not take appropriate action to address her needs. The DON was new and unaware of the issue, the LVN provided only pain medication, and the SW was out of the facility, leading to a lack of communication and follow-up.
The facility failed to label and date leftover food items in the kitchen, and staff improperly stored personal food, violating professional standards for food safety. Additionally, the stove door was broken and inadequately repaired. These issues were confirmed through staff interviews and observations.
A resident with severe cognitive impairment and urinary issues removed her catheter drainage bag, which was not replaced by the nursing staff before she was sent to the hospital. The nurse prioritized the resident's immediate safety after she was found on the floor, and the difficulty in accessing a new bag was cited. The DON acknowledged the expectation to replace the bag to prevent potential pathogen exposure.
A resident with severe cognitive impairment experienced an unwitnessed fall resulting in a subdural hematoma. Despite visible injuries, the resident was sent to the hospital via non-emergency transport, causing a 2.5-hour delay in care. The facility failed to follow its fall management policy, contributing to the deficiency.
Care Plan Not Revised for Skin Condition
Penalty
Summary
The facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after assessment for one resident. Resident #11 was admitted with diagnoses including COPD, ataxic gait, diabetes, heart disease with heart failure, and muscle weakness. The quarterly MDS indicated the resident was sometimes understood and sometimes understands, had a BIMS score of 9, required supervision for ADLs, and was at risk for pressure sores with no unhealed pressure sores, venous or arterial ulcers, or other wounds or skin problems. Physician orders dated 1/6/26 directed weekly skin evaluations and notification of the MD for any new skin condition, and a skin evaluation on 4/18/26 documented intact skin with no new areas, pressure sores, or non-pressure areas. The care plan for skin condition, initiated on 12/9/25 and revised on 12/17/25, still identified a non-pressure/surgical skin condition with interventions to assess the wound bed and surrounding skin for signs of infection or other complications. During interviews, the resident, LVN D, LVN E, the MDS nurse, and the DON all stated the resident did not currently have any skin condition and that the care plan needed to be revised to reflect that. The facility policy on Care Plan Revisions stated care plans would be reviewed and revised every quarter, when a resident experiences a status change, or as deemed necessary.
Expired medications found in medication fridge
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored in accordance with accepted professional principles for the Station 1 medication fridge. During observation, surveyors found one 25 mg Prochlorperazine suppository that expired 9/2024, six 650 mg Acetaminophen suppositories that expired 10/2025, and one Acetaminophen suppository that expired 9/2025 in the medication fridge. During interview, the DON stated medications were supposed to be removed from the fridge when they expired, but she was not sure what happened with the expired suppositories. The DON said the nurse who checked the medication fridge temperature log was responsible for checking for expired medications, and that the night shift nurses were responsible for checking the temperature log. She also stated that she and the ADON rounded on medication rooms and checked temperature logs and insulin expiration dates, but did not indicate that all medications in the fridge were routinely checked. Record review identified LVN C and RN A as the regular night nurses at Station 1. RN A stated she usually checked the medication fridge temperature at night and made sure it was within range, but she did not normally check for expired medications. She said she only checked expiration dates if she pulled out an insulin or if the fridge looked messy. The Consultant Pharmacist stated there should not be any expired medications in the medication fridge and that medications should be removed and placed in a separate area, but she was not sure who was responsible for removing expired medications. The facility policy stated outdated medication is destroyed or returned to the pharmacy according to applicable state rules and regulations.
Failure to Timely Report Verbal Abuse Allegation to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of verbal abuse to the state survey agency within 5 working days of the incident. A CNA (CNA A) was alleged to have cursed at and threatened a resident with severe cognitive impairment and PTSD during an overnight shift, and this allegation was not immediately reported by the CNA who learned of it (CNA B), nor was it reported to the state agency within the required timeframe. The report states that this failure to report could place residents at risk for abuse, neglect, exploitation, and/or mistreatment. The resident involved was an older adult with vascular dementia (severe), anxiety, dysphagia, hypertension, hyperlipidemia, cognitive communication deficit, depression, anxiety disorder, PTSD, ataxic gait, lack of coordination, psychotic disorder with delusions, and restlessness and agitation. The resident’s BIMS score was 3/15, indicating severe cognitive impairment, and the care plan documented a history of behavioral episodes including cursing, yelling, hitting other residents, pushing, and attempts to hit staff. The resident required a secure unit and had known sensitivity to noise, yelling, and commotion, which triggered PTSD and aggressive or exit-seeking behaviors. According to interviews and text records, CNA A worked the secure unit on the nights of 12/30 and 12/31 while the facility was short-staffed, caring for approximately 30 residents amid loud fireworks and gunshots in the neighborhood that caused widespread agitation and exit-seeking among residents. CNA B later reported to the DON via text that CNA A had described an encounter in which the resident approached the nurse’s station, raised his hand, and tried to hit CNA A, and that CNA A responded by saying, “Mother fucker you better not hit me or I'm gonna show you.” CNA B acknowledged in interview that she did not immediately report this verbal abuse allegation when she first learned of it from CNA A and stated she should have reported it right away. The facility’s investigation materials and interviews confirm that the allegation of verbal abuse was not reported to the state survey agency within 5 working days of the incident, constituting the cited deficiency. In addition, documentation and interviews show that bruising was later observed on the resident’s right hand and forearm, with RN A identifying the discoloration during morning rounds and documenting it as a change in condition, notifying the MD and responsible party, and obtaining an x-ray that showed osteoporosis but no fracture or dislocation. CNA B’s written statement indicated she had noticed bruising on the resident’s right forearm while providing care on a later shift but assumed it was old and did not report it at that time. While the cause of the bruising could not be determined, the core cited deficiency in the report is the facility’s failure to timely report the verbal abuse allegation involving CNA A and the resident to the state survey agency within the required 5-working-day period.
Failure to Implement Infection Control Measures for Resident With Feces-Smearing Behavior
Penalty
Summary
The deficiency involves the facility’s failure to maintain and implement an effective infection prevention and control program for a resident with known feces-smearing behavior. The resident was an adult male with schizoaffective disorder, bipolar disorder, depressive type, GERD, bowel and bladder incontinence, social isolation, and a PASRR Level II for serious mental illness. His MDS showed moderate cognitive impairment and a need for assistance with toileting. The care plan identified a focus on behaviors of eating or smearing feces, with goals and interventions related to monitoring behaviors, explaining procedures, encouraging activities, and reporting changes to the MD. Despite this, multiple episodes occurred in which the resident had feces on his hands, under his fingernails, on his face, beard, sides of his mouth, teeth, and pillow, and in or around his mouth, without consistent reporting or documentation to nursing or leadership. On one occasion, a medication aide who was also a CNA observed the resident during a medication pass placing his hand into his adult brief, pulling out feces, and attempting to put his soiled hand into his mouth. She intervened, cleaned the resident, changed his brief, and repositioned him, but did not document or report the incident to the charge nurse, assuming the behavior had already been reported. In another incident, a PTA entered the resident’s room around lunchtime and observed soiled hands, a fecal odor, and a brown tinge in the resident’s mustache, beard, chin, and teeth, with fecal odor from the resident’s mouth. The PTA cleaned the resident’s hands and fingernails, reported the situation to an LVN and to the Director of Rehabilitation, but there is no indication that this episode was documented in the medical record or that it was reported up the nursing chain as a change in condition. An anonymous source reported that the resident was known to have feces under his fingernails, on his hands, beard, sides of his mouth, and in his mouth and teeth on a recurring basis, and that a non-direct care male staff member had notified an LVN after seeing feces on the resident’s hand. According to this account, the LVN entered the room, observed the condition, stated she was not dealing with it, and left the resident as he was, after which the male staff washed the resident’s hands but could not complete full cleaning due to other duties. The LVN later stated she had been called to the room by the PTA, saw what she thought was dried chocolate on the resident’s hands, mouth, and pillow, and only later realized it was feces when the resident identified it as “poop.” She stated she called an aide to clean the resident but did not notify the resident’s nurse or MD, assuming the information had already been relayed, and believed she had documented the incident, though no such documentation was confirmed in the report. The resident himself reported episodes of diarrhea, digging in his brief, finding feces on his hands and under his fingernails, and then unknowingly rubbing his face and beard, sometimes getting feces into or around his mouth, and stated he relied on staff to clean him and change his brief and sheets afterward. Nursing leadership, including the ADM and DON, reported initially being unaware of the resident’s behavior of digging in his brief and getting feces on his hands and mouth, and the resident’s primary nurse (an LVN) stated she had not been informed of any such episodes. The ADON, who served as the infection preventionist, stated she was informed that the resident had smeared feces but only later learned that feces had been in his mouth and beard. The MDS nurse reported she care planned for feces smearing once informed but would have escalated to an IDT meeting and broader notifications had she known feces were in and around the resident’s mouth. The facility’s written infection control policy required a comprehensive infection control program with surveillance, reporting, education, and QAPI oversight, but the repeated failure of multiple staff (including an LVN, a medication aide/CNA, and a PTA) to consistently recognize, document, and report these feces-related incidents to the resident’s nurse and leadership led to the cited deficiency in infection prevention and control. Additionally, the resident had an active order for PRN ondansetron for nausea and vomiting, but the MAR for December and January showed no doses administered as of early January, despite the resident’s report of diarrhea and the NP and MD notes documenting loose stools and diarrhea. The MD ordered labs to monitor for dehydration and electrolyte imbalance, and the NP documented a chief complaint of diarrhea, but there was no documentation of ondansetron use. While the primary deficiency centers on infection control, these clinical details underscore that the resident was experiencing ongoing gastrointestinal symptoms at the time the feces-smearing and oral contamination behaviors were occurring, and that staff were aware of his diarrhea and incontinence but did not consistently integrate this information into infection control surveillance and reporting as required by the facility’s infection control program.
Failure to Protect Cognitively Impaired Resident From Verbal Abuse and Delayed Reporting of Injury
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal abuse by a CNA. The resident was an older adult with severe vascular dementia, PTSD, anxiety, depression, psychotic disorder with delusions, cognitive communication deficit, ataxic gait, and a history of behavioral episodes including hitting and pushing other residents and attempting to hit staff. His BIMS score was 3/15, indicating severe cognitive impairment, and he resided on a secure unit with care plans addressing behavior management, need for a secure environment, impaired cognition, and anticoagulant-related bruising risk. On the dates in question, the resident was known to be easily provoked by verbal aggression, loud noises, and hostility, and was particularly sensitive to environmental triggers such as fireworks and gunshots, which caused agitation and exit-seeking behaviors. According to interviews and text-message documentation, CNA A reported to CNA B that during an overnight shift on the secure unit, the resident came around the nurse’s station and tried to hit her. In response, CNA A told the resident, “Mother fucker, you better not hit me or I’m going to show you,” which constituted cursing at and threatening the resident. CNA B later confirmed in an interview and in text communication with the DON that CNA A had cussed and threatened the resident using those words. RN B described CNA A as having a loud and assertive personality that the resident did not like, and stated that the resident was extremely agitated and exit-seeking during the New Year’s Eve period due to fireworks and gunshots in the neighborhood. The facility’s behavior management and combative resident policies emphasized de-escalation, redirection, and therapeutic techniques, but there is no indication in the report that such approaches were used by CNA A during this encounter; instead, the interaction involved verbal aggression toward the resident. In addition to the verbal abuse, the report documents that bruising was later observed on the resident’s right hand and forearm. RN A first noted the bruising early in the morning during rounds, describing purple discoloration from the top of the hand to the wrist, a white area, and then purple discoloration on the forearm, with no open areas, edema, or reported pain. The resident was unable to explain how the bruising occurred. CNA B stated she had noticed bruising on the resident’s right forearm while providing care on a prior shift but assumed it was old and did not report it to a nurse at that time. The DON and ADM stated that CNA B had observed the bruising and failed to report it, and that CNA B also did not immediately report the allegation that CNA A had cussed at and threatened the resident. The physician, family, and staff interviews acknowledged the resident’s PTSD, sensitivity to loud noises and dominance, and tendency to lash out or swing his arms protectively when feeling threatened, but the cause of the bruising was not determined within the report. The deficiency centers on the facility’s failure to ensure the resident was free from verbal abuse by staff and the associated failure of timely reporting by staff who became aware of the abusive statement and the bruising. The facility’s own policies on behavior management and care of combative residents required comprehensive assessment, recognition of behavioral triggers, use of non-pharmacological interventions such as redirection and de-escalation, and prompt reporting of changes in behavior or condition to licensed staff and appropriate parties. Despite these policies and ongoing in-service training on abuse, neglect, and exploitation, the documented events show that a CNA used profane and threatening language toward a cognitively impaired, behaviorally vulnerable resident, and another CNA delayed reporting both the verbal abuse and the observed bruising. These actions and inactions directly led to the cited deficiency for failure to ensure the resident was free from abuse. The report also notes that the resident’s care plan included specific behavioral incidents over time, such as cursing, yelling, hitting other residents, and attempting to hit staff, with interventions including psychiatric evaluation, separation from other residents, attempts to move him to quieter areas, distraction, and behavior control techniques like redirection and calming. Staff interviews, including those of the DON, RNs, and the physician, consistently described the resident as highly sensitive to loud noises and perceived threats, with fireworks and gunshots on New Year’s Eve exacerbating his agitation and exit-seeking. Nonetheless, during the incident in question, the CNA’s response to the resident’s approach and attempted strike was not consistent with the resident’s identified needs or the facility’s policies, resulting in the resident being subjected to verbal abuse. Overall, the deficiency is based on the facility’s failure to ensure that the resident was free from verbal abuse by staff and the failure of staff to promptly report both the abusive interaction and the subsequent bruising observed on the resident’s wrist and forearm. These failures occurred in the context of a resident with severe cognitive impairment, PTSD, and a documented history of behavioral issues, whose care plan and diagnoses required careful, non-threatening behavioral management and adherence to abuse-prevention and reporting requirements.
Failure to Develop and Implement Comprehensive Care Plan for Recurrent Feces-Related Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes to address a resident’s identified behavioral and infection-control-related needs. The resident was an adult male with bipolar disorder, schizoaffective disorder (depressive type), GERD, and a PASRR Level II for serious mental illness. His MDS showed moderate cognitive impairment (BIMS 11/15), and he was incontinent of bowel and bladder and required assistance with toileting. Despite these factors and a documented care plan focus on PASRR-positive mental illness and a later focus on increased episodes of smearing feces, the care plan did not include specific, focused behaviors related to digging in his soiled brief, eating, or smearing feces, nor did it outline clear, measurable interventions and monitoring for these behaviors. Multiple staff observations and interviews described repeated episodes of the resident having feces on his hands, under his fingernails, on his beard and around his mouth, and in his mouth and teeth, associated with him reaching into his soiled brief. A medication aide reported seeing the resident place his hand into his brief, remove feces, and almost place his soiled hand into his mouth before she intervened; she cleaned him but did not report the incident to the charge nurse, assuming it was already care planned. An anonymous individual reported that during a holiday week, the resident was repeatedly seen with feces on his hands, beard, sides of his mouth, and in his mouth and teeth, and that an LVN entered the room, stated she would not deal with the situation, and left without addressing or reporting it, leaving non-care staff to attempt cleanup. A physical therapist assistant described entering the resident’s room and finding feces on the resident’s hands, facial hair, chin, and in his mouth and on his teeth, with a strong fecal odor, and stated this was not the first such incident he had observed. Nursing staff interviews further demonstrated that these behaviors were not consistently recognized, documented, or communicated as a change in condition requiring care plan revision. The resident himself reported repeated days of diarrhea and that he sometimes reached to the back of his brief due to discomfort, later realizing his hands and fingernails were soiled and that he would unknowingly rub his hands on his face, resulting in feces on his beard and near his mouth, describing this as a repeated pattern. The DON and administrator stated they had not been made aware of ongoing behaviors of the resident digging into his soiled brief and putting feces on or in his mouth, and the DON acknowledged that if they had known it was more than a one-time occurrence, it should have been care planned and documented in progress notes. LVNs interviewed stated they were not informed of the feces-related behaviors and indicated that, had they been aware, they would have reported them as a change in condition to the MD and leadership and expected psychiatric evaluation orders and care plan updates. The MDS nurse confirmed that the care plan was only updated to reflect feces smearing after she was informed, and that she had not known about feces in and around the resident’s mouth, which would have prompted a broader IDT care conference and notifications. Collectively, these findings show that the resident’s recurrent behavior of digging into his soiled brief and contaminating his hands and mouth was not comprehensively assessed, documented, communicated, or incorporated into a detailed, measurable care plan consistent with his assessed medical, nursing, mental, and psychosocial needs. The facility’s own baseline care plan policy required that a baseline care plan be developed within 48 hours of admission and that updates to the resident’s plan of care be made in the comprehensive care plan, including PASRR recommendations and changes in condition. Despite this, the resident’s care plan did not initially address the specific behavior of digging into his brief and contaminating his hands and mouth with feces, even after multiple staff observed such incidents. Staff interviews revealed missed opportunities to recognize and report these behaviors as changes in condition, inconsistent assumptions that the behavior was already care planned, and lack of timely documentation in progress notes. As a result, the resident’s recurrent feces-related behaviors, in the context of his mental illness, cognitive impairment, incontinence, and diarrhea, were not translated into a comprehensive, person-centered care plan with clear, measurable interventions and monitoring, as required by regulation and the facility’s own policy. Additionally, the resident’s responsible party reported not being informed of any abnormal behaviors, and some staff acknowledged uncertainty about whether the behavior required reporting or additional interventions. The assistant DON, who also served as infection preventionist, stated that the occurrence constituted a change in condition that required MD notification and that interventions such as increased rounds and more frequent brief changes were expected, but the report shows that these expectations were not consistently met prior to the survey findings. The combination of repeated, observed feces-related behaviors, lack of consistent reporting and documentation, and the absence of a fully developed, behavior-specific care plan with measurable goals and timeframes demonstrates the facility’s failure to implement a comprehensive person-centered care plan that addressed the resident’s identified medical, nursing, mental, and psychosocial needs related to this behavior.
Failure to Report and Care Plan Repetitive Feces-Ingestion Behavior in Psychiatric Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary behavioral health care and services and to promptly notify the physician after significant changes in condition for a resident with serious mental illness. Resident #2, a male with diagnoses including schizoaffective disorder (depressive type), bipolar disorder, cognitive communication deficit, and GERD, had a PASRR Level II for serious mental illness and a BIMS score indicating moderate cognitive impairment. He required assistance with toileting and was incontinent of bowel and bladder. His care plan identified a PASRR-positive status and a risk for increased episodes and injury behaviors related to smearing feces, with goals for decreased behaviors through monitoring and interventions, but the care plan did not include focused behaviors related to digging in his brief, eating, or smearing feces. Resident #2 reported during interview that he had experienced repeated days of diarrhea and, due to discomfort, sometimes dug in his soiled brief, after which feces would be on his hands and under his fingernails. He stated he had rubbed his face, beard, sides of his mouth, and possibly placed his soiled hands in his mouth, and that this behavior had been an ongoing habit. He indicated he was often unaware his hands were soiled until after he had already put them in his mouth and did not recall calling staff for assistance, though he stated staff would clean him once they discovered he was soiled. Progress notes showed that on one date a NP evaluated him for diarrhea and an MD ordered monitoring for dehydration and electrolyte imbalance with labs, but there was no documentation of episodes involving feces on his hands, face, or in his mouth. Multiple staff interviews described specific incidents where Resident #2 was observed with feces on his hands, under his fingernails, on his face and beard, and in or around his mouth and teeth, which were not properly reported, documented, or communicated to his MD. A medication aide stated she saw the resident reach into his brief, pull out feces, and attempt to place his soiled hand into his mouth; she intervened, cleaned him, but did not document or report the incident, assuming it was already known and care planned. An anonymous person reported that around the New Year holiday, the resident had feces under his fingernails, on his hands, beard, sides of his mouth, and in his mouth and teeth, and that when an unknown male staff reported this to an LVN, the LVN allegedly refused to deal with it and left the room, with the incident going undocumented and without isolation or monitoring. The PTA reported entering the resident’s room and finding feces on his hands, in his facial hair, and in his mouth and teeth, with a fecal odor, and stated he notified an LVN and then personally cleaned the resident when no one returned; he also stated this was not the first such incident. Further interviews showed that the resident’s primary nurse (LVN A) was not informed of these behaviors and stated she would have reported them as a change in condition to the DON, administrator, and MD had she known. LVN B recalled being asked by the PTA to look at what she initially thought was chocolate under the resident’s fingernails and around his mouth; she cleaned him and educated him about using the call light but did not recognize it as feces at the time and did not report it to the MD, though she acknowledged such an incident would be a change in condition requiring immediate reporting. The administrator and DON stated they were not aware of any issues reported to the MD regarding feces in or on the resident’s mouth and acknowledged the behavior was not reflected in the care plan. Facility policies required that the MD and DON be notified of changes in condition and that infection control protocols and standards of care be followed, but the episodes of feces on and in the resident’s mouth, hands, and facial hair were not consistently reported, documented, or incorporated into his behavioral health care planning, leading to the cited deficiency.
Inaccurate Medication Administration Documentation for Absent Resident
Penalty
Summary
The facility failed to maintain accurate medical records for one resident who was reviewed for resident records. The resident, a male with a history of stroke and intact cognition, was documented as having left the facility with family and did not return. Despite this, the Medication Administration Record (MAR) showed that multiple medications were documented as administered to the resident on several dates after he had already left the facility. There were no nursing progress notes indicating the resident's return after his departure, and interviews with staff and the resident's family confirmed that he did not return to the facility during this period. Medication aides and nursing staff reported that they documented medication administration in the electronic medical record after giving medications, but could not recall if the resident was present at the time of documentation. The Director of Nursing and Unit Manager confirmed that staff were expected to chart medications immediately after administration and to ensure the resident was present. The facility's policy required staff to flag the MAR if a resident was not present and follow specific guidelines, which was not done in this case. This resulted in inaccurate documentation of medication administration for a resident who was not in the facility.
Failure to Perform and Document Timely Catheter Changes Resulting in UTI and Distress
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate treatment and services to prevent urinary tract infections for residents with indwelling urinary catheters. For Resident #1, record review showed a physician’s order for an indwelling urinary catheter to be changed as needed for blockage and/or leaking, with a related care plan intervention to change the catheter, tubing, and bag per order. The care plan also noted a prior focus that the resident refused catheter changes. However, the August, September, and October 2025 Treatment Administration Records (TARs) contained no documentation of catheter changes, and progress notes did not document refusals or requests for catheter changes during that period. During observation and interview, Resident #1 reported that staff did not change her catheter every month and stated that staff became upset when she mentioned it. The resident showed the surveyor the urinary drainage bag, which had “8/28/25” written on it and contained brown discoloration; the resident also reported that the bag smelled and that, although she could not feel anything below the waist due to paraplegia, she felt anxious about the catheter not being changed. Later, the resident reported that staff changed her catheter on 10/11/25, and observation at that time showed a clean bag and tubing with no writing on the bag, but this change occurred after the period in which no changes were documented. For Resident #2, records showed a diagnosis including urinary retention and obstructive/reflux uropathy, with a physician’s order for a suprapubic indwelling urinary catheter to be changed monthly and as needed, starting 9/15/25. The September 2025 TAR documented a catheter change on 9/15/25 by LVN B. Observations on 10/9/25 and again on 10/13/25 showed the same notation on the urinary drainage bag indicating it was installed on “WED 8/27/25 14.00 HRS,” with no evidence of a subsequent bag change. Record review also showed physician orders for Macrobid and Levofloxacin for treatment of a UTI beginning on 10/13/25, and the care plan documented that the resident had frequent UTIs with an intervention for staff to provide catheter care every shift and as needed. Interviews with the Unit Manager and ADON confirmed that catheters were expected to be changed every 30 days and as needed per physician orders and that nurses were responsible for performing and documenting these changes.
Failure to Ensure Ordered Narcotic Pain Medication Was Administered and Properly Documented
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications, specifically Acetaminophen-Codeine 300-30 mg, as ordered for one resident. The resident was an adult female with paraplegia and chronic pain, admitted with a care plan that included anticipating her need for pain relief and responding immediately to any complaint of pain. Her quarterly MDS showed a BIMS score of 10, indicating moderate cognitive impairment. Physician orders dated 2/24/25 directed that she receive Acetaminophen-Codeine 300-30 mg, one tablet by mouth every 8 hours for lower back pain. Review of the resident’s MARs for multiple months showed repeated use of code 8 (“Other/See Progress Notes”) in place of documented administration of the ordered Acetaminophen-Codeine doses. In May 2025, code 8 was documented for the 8 a.m. and 4 p.m. doses on 5/27/25; in June 2025, code 8 was documented on 6/28/25 at 8 a.m. and on 6/29/25 at 12 a.m., 8 a.m., and 4 p.m.; in August 2025, code 8 was documented on 8/31/25 at 8 a.m.; in September 2025, code 8 was documented on 9/30/25 at midnight; and in October 2025, code 8 was documented on 10/1/25 at midnight, 8 a.m., and 4 p.m. Review of the resident’s progress notes from 9/13/25 to 10/14/25 did not reveal any further documentation explaining the code 8 entries on 9/30/25 and 10/1/25 or confirming that the medication was administered at those times. In interviews, the resident stated that the facility was supposed to have her medication on time but reported that staff told her the medication was not available and blamed the pharmacy, and that this problem had been occurring monthly since the previous year. She reported that when she did not receive her pain medication, she felt terrible, could not sleep, her tailbone hurt, and she developed a headache. A medication aide reported that she usually administered Tylenol #3 to this resident twice a day, that she had to notify the nurse to reorder narcotics, and that if she documented code 8 on the MAR it meant she likely notified the nurse and did not give the medication because it was not available, possibly due to pharmacy delays; she could not recall the specific reason for the 8/31/25 entry and did not know where the nurse would document if the medication was given from the automated dispensing system. An LVN and the ADON both stated that nurses were responsible for reordering narcotics and denied problems with reordering, though the ADON acknowledged that if a narcotic was not refilled in time there could be unmanaged pain and that the Tylenol #3 was available in the automated dispensing system, but could not explain why the medication was not given. The facility’s policy stated that medications shall be administered as prescribed by the attending physician.
Resident Elopement Due to Inadequate Supervision and Unsecured Exit
Penalty
Summary
The facility failed to provide adequate supervision and assistance devices to prevent accidents for a resident diagnosed with vascular dementia, who eloped from the facility to a nearby tire shop. The resident, who was severely cognitively impaired, was missing for about an hour before being found by police and returned to the facility. The incident occurred because the resident exited through a side door that was not alarmed and was not part of the facility's secured unit. Staff did not notice the resident was missing until a family member called to inform them. The resident's admission records did not include an elopement risk assessment, which should have been completed upon admission. The resident had no documented history of wandering or exit-seeking behaviors prior to the incident. On the day of the elopement, the resident was last seen by a CNA around 6:00 pm, and staff did not realize the resident was missing until 6:30 pm when the family member called. The facility's daily sign-in sheet indicated that staff worked 12-hour shifts, and the resident was under the care of various staff members throughout the day. The facility's elopement policy required routine elopement risk assessments and appropriate supervision, which were not adequately followed in this case. The facility's incident and accident report confirmed that this was the only elopement incident involving the resident from August 2024 through February 2025. The lack of an elopement risk assessment and the unsecured side door contributed to the resident's ability to leave the facility unnoticed.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for at least eight consecutive hours per day, seven days a week, as required. This deficiency was noted on four specific days in September 2024: the 1st, 14th, 15th, and 29th. Interviews with the Director of Nursing (DON) and the Administrator revealed that the facility did not have adequate RN coverage on these days. The DON, who started in October 2024, was not present during the time of the deficiency, and the Administrator, who began in December 2024, was unaware of any issues prior to her tenure. The facility's human resources department, responsible for completing the PBJ report, had a change in personnel, which may have contributed to the oversight. Record reviews confirmed that on the specified dates, the RNs did not work the required eight consecutive hours. For instance, RN H and RN G worked partial shifts that did not meet the eight-hour requirement. Additionally, the facility's incident reports indicated that there were fall incidents and episodes of physical aggression on some of these dates, although there was no documented increase in incidents compared to the rest of the month. The lack of consistent RN coverage could potentially place residents at risk of not receiving adequate care, as RNs are essential for performing necessary assessments.
Failure to Transmit MDS Data Timely
Penalty
Summary
The facility failed to transmit encoded, accurate, and complete Minimum Data Set (MDS) data to the CMS System within the required 14 days after completing the resident's assessment for two residents. For one resident, the Admission MDS assessment was completed 16 days after admission, exceeding the required timeframe. Another resident's Discharge MDS assessment was completed 24 days after the required completion date. These delays in transmitting MDS data could potentially impact the timely completion of care plans and result in denial of services or payment. Interviews with facility staff revealed that the MDS coordinator completed the assessments as required but had to wait for RN signatures, which contributed to the delay in transmission. The MDS coordinator also mentioned that the discharge MDS for one resident was not completed in a timely manner because it was initially done by a staff member who no longer worked at the facility. The Director of Nursing (DON) stated that she was not trained to sign the MDS, and a corporate staff member was responsible for signing off on the MDS. The facility's policy on MDS completion and transmission was requested, and the MDS coordinator indicated adherence to the RAI manual.
Failure to Provide Routine Dental Care for Resident
Penalty
Summary
The facility failed to assist a resident in obtaining routine dental care, which was identified during a survey. The resident, a female with severe cognitive impairment and multiple health conditions, including pain and dementia, complained of tooth pain and difficulty chewing. Despite these complaints, the resident was not referred to a dentist. The resident's care plan indicated dental concerns and a risk for increased pain and infections, but no action was taken to address her dental needs. Interviews with facility staff revealed a lack of communication and follow-up regarding the resident's dental care needs. The Director of Nursing (DON) was new and unaware of the resident's dental issues, while the Licensed Vocational Nurse (LVN) acknowledged the resident's complaints of mouth pain but only provided pain medication without referring her to a dentist. The Social Worker (SW) was also unaware of the resident's need for dental services due to being out of the facility for an extended period. The facility's policy stated that dental services are the responsibility of the resident or Medicaid, but it did not address situations where the facility would cover costs if a resident was in pain.
Deficiency in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its kitchen, as observed during a survey. Specifically, the facility did not label and date leftover food items in three coolers, which included coleslaw, tuna, a brown substance, pudding, and Jello. Additionally, food brought from home by staff was not labeled, dated, or stored in a designated refrigerator outside the kitchen. These practices were identified through observations and interviews with kitchen staff, including a cook and the Dietary Manager, who acknowledged the lapses in labeling and dating food items. Further issues were noted with the kitchen equipment, as the stove door was broken and temporarily held in place with cardboard. The Dietary Manager confirmed that the stove door had been broken since around Christmas and had informed the Maintenance Manager, who no longer worked at the facility, but did not document the conversation. Interviews with the Dietary Aide and the facility's Administrator revealed that staff were aware of the policy against storing personal food in the kitchen cooler, yet the policy was not followed. The facility's policy on food safety emphasized the importance of labeling and dating food to prevent contamination and bacterial growth.
Failure to Replace Catheter Bag After Removal
Penalty
Summary
The facility failed to provide appropriate care for a resident who was incontinent of bladder, specifically in replacing a foley catheter drainage bag after it was removed by the resident. The resident, a female with severe cognitive impairment and medical conditions including urine retention and obstructive uropathy, pulled off her catheter drainage bag. A CNA reported the incident to a nurse, who prioritized assessing the resident's safety after she was found on the floor, rather than replacing the catheter bag. The nurse did not replace the catheter bag before the resident was sent to the hospital, citing the need to focus on the resident's immediate safety and the difficulty in accessing a new bag due to a locked supply closet. The Director of Nursing (DON) acknowledged that the catheter bag was on the floor and that the nurse was focused on the resident's neurological status and calling emergency services after the resident hit her head. The DON stated that the expectation would have been to replace the catheter bag to ensure proper drainage and prevent potential exposure to pathogens. The facility's policy requires nursing staff to demonstrate competencies necessary to care for residents, which was not adhered to in this instance, potentially placing the resident at risk for urinary tract infections.
Delayed Emergency Response After Resident Fall
Penalty
Summary
The facility failed to ensure that a resident received timely emergency care following an unwitnessed fall, which resulted in a subdural hematoma. The resident, who had severe cognitive impairment and was at risk for falls due to dementia and other conditions, was found on the floor with a head injury. Despite the presence of a bump over the left eye and a split lip, the resident was sent to the hospital via non-emergency transport, leading to a 2.5-hour delay in receiving care. Interviews with staff revealed that the LVN on duty assessed the resident and determined that the vitals were stable, opting for non-emergency transport based on previous fall incidents and the resident's baseline condition. The LVN was not trained to document neuro checks and did not perceive the situation as requiring immediate emergency services. The facility's policy required emergency services to be initiated if a fall was life-threatening, but this protocol was not followed. The delay in emergency care was identified as an Immediate Jeopardy situation, indicating a significant risk to the resident's health and safety. The facility's failure to adhere to its fall management policy and the lack of proper training and documentation contributed to the deficiency, placing the resident at risk for further injury.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 566 citations issued within 25 miles in the last 12 months — including the 50 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Pasadena
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pasadena Post Acute | 2 mi | ★★★★★ | 6 | 0 |
| Focused Care At Pasadena | 2.1 mi | ★★★★★ | 8 | 0 |
| Avir At Pasadena | 2.2 mi | ★★★★★ | 3 | 0 |
| The Courtyards At Pasadena | 3.2 mi | ★★★★★ | 8 | 0 |
| Hca Houston Healthcare Southeast | 4 mi | — | 0 | 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.