Inspection Reports for Paradigm at First Colony
4710 Lexington Blvd, Missouri City, TX 77459, United States, TX, 77459
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 1, 2025, identified a deficiency related to the facility’s failure to allow a resident’s representative to exercise the resident’s rights. Earlier inspections showed a pattern of deficiencies involving resident rights, care planning, supervision, medication administration, infection control, and safety practices. Inspectors frequently cited issues with failure to develop and implement comprehensive care plans, inadequate supervision, delayed or improper treatment, and lapses in infection prevention and privacy protections. Several complaint investigations were substantiated, including neglect, failure to report abuse timely, and inadequate notification to family members, though immediate jeopardy findings were removed after corrective actions and no fines or license suspensions were listed in the available reports. The facility’s inspection history reflects ongoing challenges with compliance, with some corrective actions noted but no clear sustained improvement trend.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
15 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
329% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 1, 2025
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to ensure that a resident's representative had the right to exercise the resident's rights as provided by state law.
Complaint Details
The complaint involved Resident #1's POA being denied rights by the facility, with the Administrator claiming the POA was invalid due to the resident's cognitive impairment and dementia. Interviews with the POA, APS worker, Social Worker, and the resident indicated the POA was valid and had rights to visit and assist the resident. The APS case was closed with no allegations against the POA.
Findings
The facility failed to provide clinical records to Resident #1's Power of Attorney (POA) and did not recognize the POA as valid, despite documentation and interviews indicating the POA's rights were legitimate. This failure could place residents at risk of unmet needs or disrupted continuity of care.
Deficiencies (1)
Failed to give the resident's representative the ability to exercise the resident's rights.
Report Facts
BIMS score: 11
Date of History and Physical: Mar 15, 2025
Date of admission consent: Mar 15, 2025
Date of Psychosocial Evaluation: Mar 17, 2025
Date of Social Services progress note: Mar 31, 2025
Date of POA document: Apr 15, 2025
Interview date with POA: Oct 8, 2025
Interview date with APS worker: Oct 8, 2025
Interview date with Social Worker: Oct 8, 2025
Interview date with Administrator: Oct 8, 2025
Interview date with Resident: Oct 9, 2025
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Nov 14, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with resident rights, specifically ensuring residents had the right to reside and received services with reasonable accommodations of their needs and preferences.
Findings
The facility failed to ensure that call lights were within reach for 2 of 12 residents reviewed, which could place residents at risk of their needs not being met. Observations and interviews confirmed call lights were not properly positioned for Resident #1 and Resident #2 on 11/12/2025.
Deficiencies (1)
Failed to ensure residents' call lights were within reach, placing residents at risk of unmet needs.
Report Facts
Residents reviewed for rights: 12
Residents affected: 2
BIMS score Resident #1: 13
BIMS score Resident #2: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Interviewed regarding call light placement and resident assistance |
| DON | Director of Nursing | Provided expectations for call light placement and staff training |
| ADM | Administrator | Stated expectations for call light placement and staff responsibilities |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 8, 2025
Visit Reason
The inspection was conducted due to multiple allegations of abuse, neglect, and exploitation involving several residents, triggered by complaints and reports from residents, family members, and an insurance provider.
Complaint Details
The complaint investigation involved allegations from residents and family members about rough care by staff during activities of daily living and medication pass, failure to provide essential care, physical aggression between residents, and concerns of possible sexual assault and unsanitary conditions. The facility failed to submit required five-day investigation reports for these allegations, which were substantiated as unreported or not thoroughly investigated.
Findings
The facility failed to provide evidence that all alleged violations of abuse were thoroughly investigated and reported to the State Survey Agency within five working days for 6 of 8 residents reviewed. The facility did not submit required five-day investigation reports for multiple incidents involving rough care, neglect, and possible sexual assault, placing residents at risk.
Deficiencies (1)
Failed to provide evidence that all alleged violations of abuse were thoroughly investigated and reported within five working days for 6 of 8 residents.
Report Facts
Residents reviewed for abuse: 8
Residents with unreported investigations: 6
Dates of incidents: Incidents occurred on 12/26/2024, 02/25/2025, 02/10/2025, 09/16/2024, among others
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Identified as providing rough care during ADL assistance; suspended during investigation | |
| MA L | Identified as providing rough care during medication pass; suspended during investigation | |
| CNA R | Alleged failure to provide essential care; suspended during investigation | |
| Regional Nurse | Provided statements regarding investigations and facility procedures | |
| Administrator | Facility's abuse coordinator; acknowledged failure to submit five-day reports | |
| Former Administrator FS M | Responsible for failure to submit required investigation reports |
Inspection Report
Routine
Deficiencies: 2
Date: Jun 1, 2025
Visit Reason
The inspection was conducted to evaluate the facility's pharmaceutical services and medication administration practices, specifically focusing on the administration of eye drops to Resident #1.
Findings
The facility failed to provide proper pharmaceutical services for Resident #1 by not following correct procedures for administering eye drops, including not pulling down the lower eyelid and placing the medication cap on an unclean surface, which could risk infection or improper dosing.
Deficiencies (2)
Failure to pull down the lower eyelid prior to instilling medicated eye drops to Resident #1.
Medication cap for eye drops was placed on an unclean surface with the inside facing down before replacing the cap onto the bottle.
Report Facts
Residents Affected: 1
Medication order date: Jan 19, 2025
Medication administration record date: Jun 1, 2025
Medication Aide competency checklist date: Mar 2, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MA-A | Medication Aide | Named in deficiency for improper eye drop administration |
| LVN-B | Licensed Vocational Nurse | Provided interview on proper eye drop administration and follow-up actions |
| DON | Director of Nursing | Provided interview on expected medication administration procedures and planned in-service training |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 21, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide appropriate treatment and care according to orders, resident preferences, and goals, specifically related to an unwitnessed fall with head injury of a resident on anticoagulant medication.
Complaint Details
The complaint investigation focused on the facility's failure to appropriately respond to an unwitnessed fall with head injury of a resident on anticoagulants, resulting in delayed hospital transfer and serious injury. The facility was also investigated for inadequate supervision and fall prevention interventions for the same resident who had multiple falls.
Findings
The facility failed to ensure residents received treatment and care in accordance with professional standards, comprehensive care plans, and residents' choices. Specifically, the facility delayed sending a resident (CR #1) on anticoagulants to a higher level of care after an unwitnessed fall with head injury, resulting in an acute subdural hematoma and hospitalization. The facility also failed to provide adequate supervision and interventions to prevent multiple falls for CR #1, who had dementia and was at high risk for falls. Immediate Jeopardy was identified but later removed; however, the facility remained out of compliance with potential for more than minimal harm.
Deficiencies (2)
Failure to provide appropriate treatment and care according to orders, resident preferences, and goals, resulting in delayed hospital transfer after unwitnessed fall with head injury for resident on anticoagulants.
Failure to provide adequate supervision and interventions to prevent falls for a resident on anticoagulants with dementia, resulting in multiple unwitnessed falls and hospitalization.
Report Facts
Fall incidents: 4
Fall risk assessment scores: 25
Fall risk assessment scores: 19
Medication dosage: 5
Time of fall: 550
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Administered medication, assessed resident after fall, called physician and family, involved in delayed hospital transfer decision |
| CNA B | Certified Nursing Assistant | Assisted with resident care on day of fall, not assigned CNA for CR #1 but assisted with getting resident out of bed |
| CNA C | Certified Nursing Assistant | Assigned CNA for CR #1, assisted RN A after fall, last to see resident before fall |
| DON | Director of Nursing | Interviewed regarding fall policies, in-serviced staff, involved in Plan of Removal and QAPI meetings |
| Administrator | Nursing Facility Administrator | Interviewed regarding fall events, policies, and Plan of Removal; involved in QAPI meetings |
| Medical Director | Medical Director | Interviewed regarding medication administration and fall response policies |
| Medication Aide RR | Medication Aide | Administered Eliquis medication to CR #1 on day of fall |
| Regional Nurse Consultant | Regional Nurse Consultant | Provided education to DON and staff on fall procedures and emergency response |
| MDS Coordinator | Minimum Data Set Coordinator | Reviewed and updated care plans after falls, interviewed about fall prevention interventions |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Nov 19, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to maintain residents' privacy and confidentiality of medical records, and failure to post daily nursing staffing information as required.
Complaint Details
The visit was complaint-related, focusing on privacy violations and staffing posting failures. The complaint was substantiated based on observations, interviews, and record reviews.
Findings
The facility failed to ensure that a Certified Medication Aide (CMA A) locked the computer screen displaying residents' protected health information, violating HIPAA privacy rules. Additionally, the facility failed to post daily nursing staffing information from 11/14/24 to 11/19/24, which could affect residents and visitors by limiting access to staffing information.
Deficiencies (3)
Failed to ensure residents' rights to privacy by not locking the computer screen displaying names of 7 residents during medication administration.
Failed to keep medical records secure and confidential by allowing clinical information to be divulged in halls.
Failed to post daily nursing staffing information from 11/14/24 to 11/19/24.
Report Facts
Residents reviewed for privacy: 10
Residents affected: 7
Days staffing information not posted: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Aide (CMA A) | Failed to lock computer screen displaying resident information | |
| Registered Nurse (RN A) | Interviewed regarding privacy and HIPAA violations | |
| Staffing Coordinator | Responsible for posting daily nursing staffing information but failed to update it | |
| Administrator | Provided information about staffing posting responsibilities and policies |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Oct 24, 2024
Visit Reason
The inspection was conducted based on complaints alleging failure to ensure residents' rights to dignity and respect, failure to report and investigate abuse allegations, failure to develop comprehensive care plans, failure to properly manage intravenous fluids and PICC lines, and failure to provide appropriate respiratory care.
Complaint Details
The complaint investigation was triggered by allegations of resident abuse, neglect, failure to respect resident rights, and failure to provide appropriate care including IV and respiratory care. Substantiation status is not explicitly stated.
Findings
The facility was found deficient in multiple areas including failure to respect residents' dignity, failure to immediately report and investigate abuse allegations, failure to develop and implement comprehensive care plans for residents, failure to properly manage PICC lines and intravenous fluids, and failure to provide sterile technique during tracheostomy care. Immediate jeopardy was identified related to PICC line management but was removed after corrective actions.
Deficiencies (5)
Failure to ensure residents' right to respect and dignity; staff laughed and called a resident 'crazy' while redirecting him.
Failure to immediately report suspected abuse of Resident #91 involving allegations of being slapped by staff.
Failure to develop and implement comprehensive care plans addressing oxygen cannula management for Resident #88 and skin issues for Resident #43.
Failure to ensure safe and appropriate administration of IV fluids and management of PICC line for Resident #37, including lack of physician orders for PICC line care and failure to remove PICC line after antibiotic completion.
Failure to ensure sterile technique during tracheostomy care and suctioning for Resident #200.
Report Facts
Residents reviewed for respect and dignity: 8
Residents affected by abuse reporting failure: 1
Residents reviewed for comprehensive care plans: 3
Days PICC line dressing not changed: 27
Duration of IV antibiotic therapy: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN M | Named in failure to report abuse allegation involving Resident #91 | |
| RN G | Observed failing to use sterile technique during tracheostomy care for Resident #200 | |
| ADM A | Administrator | Interviewed regarding abuse reporting and PICC line management |
| ADM B | Interim Administrator and Abuse Coordinator | Responsible for abuse reporting during part of the investigation period |
| DON | Director of Nursing | Interviewed regarding abuse reporting, PICC line management, and tracheostomy care |
| NP A | Nurse Practitioner | Responsible for physician orders related to PICC line for Resident #37 |
| CNA M | Named in disrespectful behavior toward residents | |
| MA J | Named in disrespectful behavior toward residents |
Inspection Report
Routine
Deficiencies: 10
Date: Oct 24, 2024
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including care planning, pressure ulcer care, infection control, medication administration, food safety, and other resident care standards.
Findings
The facility was found deficient in multiple areas including failure to develop timely and comprehensive care plans for residents, inadequate pressure ulcer care, improper catheter care, failure to properly manage PICC lines and intravenous fluids, medication administration errors, food safety violations including improper food storage and drain water backup, and lapses in infection prevention and control practices.
Deficiencies (10)
Failure to develop a person-centered baseline admission care plan within 48 hours for Resident #43.
Failure to develop and implement a comprehensive person-centered care plan with measurable objectives for Residents #88 and #43.
Failure to provide appropriate pressure ulcer care and prevent new ulcers for Residents #60 and #155.
Failure to provide appropriate care for residents incontinent of bladder, including proper catheter care for Resident #155.
Failure to provide safe and appropriate administration of IV fluids and management of PICC line for Resident #37, including failure to discontinue PICC line after antibiotic therapy completion.
Failure to provide safe and appropriate respiratory care including sterile technique during tracheostomy care and suctioning for Resident #200.
Medication administration errors for Residents #83 and #205, including incorrect medication preparation and administration.
Failure to procure food from approved sources and store, prepare, distribute, and serve food in accordance with professional standards, including improper food labeling, storage, and drain water backup in kitchen.
Failure to properly dispose of garbage and keep dumpster doors closed to prevent infection risk.
Failure to maintain an infection prevention and control program, including improper disinfection of oxygen cannula for Resident #88.
Report Facts
Medication error rate: 15
PICC line dressing change frequency: 5
Food discard timeframe: 72
Braden Score: 17
BIMS score: 15
BIMS score: 12
BIMS score: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN G | Registered Nurse | Named in findings related to improper tracheostomy care and oxygen cannula handling |
| MDS Coordinator A | Named in findings related to care planning deficiencies for Resident #43 | |
| MDS Coordinator B | Named in findings related to care planning deficiencies for Resident #43 | |
| MA A | Named in medication administration errors | |
| RN A | Named in medication administration errors | |
| LVN C | Licensed Vocational Nurse | Named in wound care deficiencies and catheter care |
| DON | Director of Nursing | Named in multiple interviews regarding care deficiencies and corrective actions |
| DFSM | Dietary Food Service Manager | Named in food safety and kitchen drain water backup findings |
| ADM A | Administrator | Named in food safety and infection control findings |
| LVN E | Licensed Vocational Nurse | Named in wound care and mattress ordering |
| NP A | Nurse Practitioner | Named in PICC line management and order deficiencies |
Inspection Report
Deficiencies: 1
Date: Aug 21, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with maintaining clinical records in accordance with accepted professional standards, specifically reviewing the accuracy and completeness of pain documentation for Resident #1.
Findings
The facility failed to ensure that Resident #1's pain level was documented in the clinical record when pain medication was ordered. Despite the resident expressing pain and the doctor ordering Norco, there was no documentation of the pain level in the nurse's progress notes or pain assessment log. The Director of Nursing confirmed the nurse likely forgot to document the pain level.
Deficiencies (1)
Failure to document Resident #1's pain level in the clinical record when pain medication was ordered.
Report Facts
Pain assessment scores: 6
Pain assessment scores: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN G | Licensed Vocational Nurse | Nurse who failed to document Resident #1's pain level and called the doctor to order pain medication |
| Doctor J | Physician | Doctor who assessed Resident #1 and ordered Norco for pain |
| Director of Nursing | Interviewed regarding documentation practices and nurse's failure to document pain level |
Inspection Report
Routine
Deficiencies: 2
Date: Jul 25, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with professional standards regarding resident clinical records, call light system functionality, and resident safety following a resident-to-resident altercation.
Findings
The facility failed to maintain accurate and complete clinical records for residents, including incorrect demographic information and incomplete incident documentation related to a resident-to-resident altercation. Additionally, the facility failed to ensure a functional call light system for one resident, putting residents at risk of not being able to call for assistance when needed.
Deficiencies (2)
Failed to maintain clinical records on each resident that were complete and accurately documented, including incorrect race noted on Resident #2's Facesheet and failure to document a resident-to-resident altercation in incident reports.
Failed to have an adequately equipped call light system that allowed Resident #1 to call for staff assistance; call light button was missing and non-functional.
Report Facts
Residents reviewed for accuracy and completeness: 4
Residents reviewed for call light button placement: 5
BIMS score: 14
BIMS score: 10
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN J | Charge Nurse | Completed SBAR and progress notes for Resident #3 after altercation; only documented on resident who received the hit. |
| RN S | Nurse | Resident #1's nurse who acknowledged call light button was missing and non-functional. |
| CNA B | Certified Nursing Assistant | Made rounds and noted Resident #1's call light was missing the push button. |
| Maintenance Director | Responsible for fixing call lights when notified; was not informed about Resident #1's call light issue. | |
| Unit Manager | Informed about Resident #1's call light issue and emphasized staff responsibility to check call light functionality. | |
| ADON | Assistant Director of Nursing | Stated aides and nurses should check call light functionality before placing within reach. |
| DON | Director of Nursing | Stated call light should be functional before placement; acknowledged risk to Resident #1 without functional call light. |
| Administrator | Expected residents to have functional call lights to call for help when needed. | |
| SW | Social Worker | Presented ANE in-service and was involved in resident-to-resident altercation follow-up. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 8, 2024
Visit Reason
The inspection was conducted based on complaints regarding inadequate incontinent care and infection prevention practices at the facility.
Complaint Details
The complaint investigation found substantiated deficiencies related to incontinent care and infection control practices affecting Residents #1 and #2.
Findings
The facility failed to provide timely incontinent care to Resident #2, resulting in risk for skin impairment and urinary tract infections. Additionally, the facility failed to maintain an effective infection prevention and control program, including failure to label personal care items and improper hand hygiene by staff, placing residents at risk for infections and decreased quality of life.
Deficiencies (2)
Failed to provide Resident #2 incontinent care for over 3 hours, placing resident at risk for skin impairment and urinary tract infections.
Failed to establish and maintain an infection prevention and control program, including failure to label personal care items and failure of CNA A to practice hand hygiene while providing care for Resident #2.
Report Facts
Residents affected: 1
Residents affected: 2
Medication dosage: 100
Medication duration: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Named in findings for failure to provide timely incontinent care and failure to practice hand hygiene |
| CNA C | Certified Nursing Assistant | Assisted CNA A in providing incontinent care |
| RN B | Registered Nurse | Resident #1 and #2's nurse, interviewed regarding labeling of personal care items |
| DON | Director of Nursing | Interviewed regarding infection control practices and staff in-service plans |
| Administrator | Facility Administrator | Interviewed regarding facility policy on Quality of Life |
| Infection Control Nurse | Infection Control Nurse | Interviewed regarding labeling of personal care items to prevent cross contamination |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 2, 2023
Visit Reason
The inspection was conducted based on complaints and observations regarding the facility's failure to develop and implement accurate, comprehensive, person-centered care plans and to ensure safe smoking practices and adequate supervision for residents who smoke.
Complaint Details
The complaint investigation focused on unsafe smoking practices and inadequate care planning for residents who smoke. Observations and interviews revealed residents smoking unsupervised outside scheduled times, possession of lighters and cigarettes against care plans, and staff not enforcing policies. The Administrator and Regional Nurse Consultant acknowledged failures in care plan implementation and supervision.
Findings
The facility failed to develop and implement accurate care plans for residents, specifically regarding safe smoking interventions. Residents were observed smoking outside of scheduled hours unsupervised, possessing lighters and cigarettes contrary to care plans and facility policies. Staff and administration were unaware or failed to enforce smoking policies, placing residents at risk of harm.
Deficiencies (2)
Failed to develop and implement an accurate comprehensive person-centered care plan for Resident #5, including safe smoking goals and interventions.
Failed to ensure adequate supervision to prevent accidents related to smoking for Residents #4, #5, and #6, who smoked outside scheduled hours unsupervised and possessed smoking materials contrary to policy.
Report Facts
Residents reviewed for care plans: 6
Residents reviewed for accidents, hazards, and supervision: 6
Smoking schedule times: 5
BIMS score Resident #5: 11
BIMS score Resident #6: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding smoking policies, expectations, and care plan implementation failures. | |
| Regional Nurse Consultant | Interviewed regarding smoking assessments, care plans, and facility responsibilities. | |
| Nurse Manager A | Nurse Manager | Interviewed about Resident #6 and smoking supervision. |
| LVN C | Licensed Vocational Nurse | Interviewed about residents in the courtyard and smoking supervision. |
| Administrator in Training | Interviewed about smoking policies and staff knowledge. |
Inspection Report
Routine
Deficiencies: 6
Date: Sep 8, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care planning, respiratory care, nutrition services, food safety, and waste disposal at Paradigm at First Colony nursing home.
Findings
The facility failed to complete baseline care plans within the required timeframe for some residents, did not develop comprehensive care plans addressing all resident needs, failed to provide appropriate respiratory care including timely changing of nebulizer masks, did not follow menus resulting in missing food items, failed to ensure proper dishwashing sanitization, and did not properly manage dumpster lids and refuse disposal.
Deficiencies (6)
Failed to develop and implement baseline care plans within 48 hours for residents #14 and #60.
Failed to develop and implement a comprehensive care plan including measurable objectives for resident #13, specifically not care planning for resting splint to right hand.
Failed to provide safe and appropriate respiratory care; Resident #108's nebulizer mask was not changed in over 14 days.
Failed to ensure menus were followed; milk was not served at breakfast on 9/5/2023 and bread was not served at lunch on 9/6/2023.
Failed to store, prepare, distribute and serve food in accordance with professional standards; dishwashing machine was not dispensing chlorine sanitizing solution and no documentation of temperature or sanitizer levels at lunch.
Failed to properly dispose of garbage and refuse; dumpster lids were open and refuse was present around dumpsters.
Report Facts
BIMS score: 0
BIMS score: 12
BIMS score: 11
BIMS score: 14
Nebulizer mask change interval: 14
Milk quantity: 7
Dishwashing machine chlorine sanitizer test strips expiration: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse A | Nurse | Mentioned in relation to failure to complete baseline care plan for Resident #14 |
| Regional Nurse Consultant | Nurse Consultant | Provided information about baseline care plan procedures and Resident #60's care plan status |
| MDS Coordinator | MDS Coordinator | Provided information about baseline care plans and Resident #13's splint care planning |
| Director of Rehabilitation | Director of Rehabilitation | Discussed responsibility for care planning of Resident #13's splint |
| RN X | Registered Nurse | Provided information about nebulizer mask and tubing change frequency |
| DON | Director of Nursing | Provided information about oxygen tubing and nebulizer mask change procedures |
| Kitchen Manager | Kitchen Manager | Discussed menu deviations, dishwashing machine issues, and dumpster lid management |
| Administrator | Administrator | Provided information about menu adherence and dishwashing sanitization importance |
| Dietician | Dietician | Expressed concern about residents not receiving milk and bread as per menu |
| Dietary Aide A | Dietary Aide | Mentioned in relation to dishwashing machine sanitizing solution testing and usage |
Inspection Report
Routine
Deficiencies: 6
Date: Sep 8, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with regulatory requirements related to resident care planning, respiratory care, nutrition services, food safety, and waste disposal.
Findings
The facility failed to complete baseline care plans within the required timeframe for some residents, did not develop comprehensive care plans addressing all resident needs, failed to provide appropriate respiratory care including timely changing of nebulizer masks, did not follow menus resulting in missing food items, failed to ensure proper dishwashing sanitization, and did not properly manage dumpster lids and refuse disposal.
Deficiencies (6)
Failure to complete baseline care plans within 48 hours for residents #14 and #60.
Failure to develop and implement a comprehensive care plan including measurable objectives for resident #13, specifically not care planning for resting splint to right hand.
Failure to provide safe and appropriate respiratory care for resident #108; nebulizer mask not changed in over 14 days.
Failure to ensure menus were followed; residents not served milk at breakfast on 9/5/2023 and bread at lunch on 9/6/2023.
Failure to store, prepare, distribute and serve food in accordance with professional standards; dishwashing machine not dispensing chlorine sanitizing solution and lack of documentation of temperature and sanitizer levels at lunch.
Failure to properly dispose of garbage and refuse; dumpster lids open and refuse around dumpsters.
Report Facts
BIMS score: 0
BIMS score: 12
BIMS score: 11
BIMS score: 14
Gallons of milk: 7
Dishwashing machine chlorine sanitizer test strips expiration: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse A | Nurse | Named in relation to failure to complete baseline care plan for Resident #14 |
| MDS Coordinator | Interviewed regarding baseline care plans and care planning process | |
| Regional Nurse Consultant | Interviewed regarding baseline care plan requirements and resident #60 | |
| Director of Rehabilitation | Interviewed regarding care planning for Resident #13's splint | |
| RN X | Registered Nurse | Interviewed regarding respiratory care and nebulizer mask |
| DON | Director of Nursing | Interviewed regarding oxygen therapy and nebulizer mask care |
| Kitchen Manager | Interviewed regarding menu deviations, dishwashing machine issues, and dumpster lids | |
| Dietician | Interviewed regarding menu adherence and nutritional concerns | |
| Dietary Aide A | Observed using dishwashing machine and interviewed about sanitizing procedures | |
| Administrator | Interviewed regarding menu issues, dishwashing sanitization, and waste disposal |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Aug 15, 2023
Visit Reason
The inspection was conducted due to complaints and allegations regarding neglect, inadequate wound care, failure to provide CPR, and unsafe resident supervision at Paradigm at First Colony nursing home.
Complaint Details
The complaint investigation revealed substantiated neglect involving failure to provide wound care, failure to provide CPR, failure to supervise residents adequately, and failure to implement care plans, resulting in resident harm and death.
Findings
The facility failed to protect residents from neglect, ensure appropriate wound care, provide CPR, and adequately supervise residents, resulting in multiple pressure ulcers, an unwitnessed fall, and a resident found unresponsive and deceased. Immediate Jeopardy was identified but later removed with ongoing noncompliance at actual harm level.
Deficiencies (5)
Failed to ensure residents were free from neglect, including failure to provide appropriate wound care and CPR, and failure to investigate incidents thoroughly.
Failed to develop and implement comprehensive person-centered care plans for residents, including pain management, pressure ulcer prevention, and behavioral care.
Failed to provide basic life support including timely CPR and immediate contact of emergency services for a resident found unresponsive.
Failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for multiple residents, including failure to follow physician orders and provide wound care documentation.
Failed to ensure adequate supervision and safe transfers, including leaving a resident unattended on a Hoyer lift and inadequate monitoring after a fall.
Report Facts
Deficiencies cited: 5
Pressure ulcer sizes: 7.5
Pressure ulcer sizes: 5.3
Pressure ulcer sizes: 5.5
Pressure ulcer sizes: 2.5
Pressure ulcer sizes: 9
Pressure ulcer sizes: 0.8
Wound size: 12
Wound size: 18.5
Wound size: 1.5
Wound surface area: 222
Wound size: 6
Wound size: 5.5
Wound size: 0.5
Wound surface area: 33
Wound size: 1
Wound size: 0.5
Wound size: 0.3
Wound surface area: 0.5
Wound size: 6.5
Wound size: 7
Wound size: 1.5
Wound surface area: 45.5
Wound size: 7
Wound size: 8
Wound size: 0.5
Wound surface area: 56
Wound size: 3
Wound size: 2
Wound size: 0.2
Wound surface area: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Assessed CR#1 after fall, notified NP and family, documented neuro checks, and communicated with family. |
| CNA A | Certified Nursing Assistant | Found CR#1 on floor after fall, provided care, and reported to LVN A. |
| Wound Care Nurse | Provided wound care for CR#1 and CR#2, involved in air mattress placement and wound assessments. | |
| LVN E | Licensed Vocational Nurse | Assessed CR#8 when found unresponsive, initiated CPR, called 911, and communicated with police and family. |
| CNA C | Certified Nursing Assistant | Found CR#8 on floor unresponsive, notified LVN E, assisted with CPR. |
| DON | Director of Nursing | Provided interviews regarding air mattress use, fall investigations, and staff training. |
| NP | Nurse Practitioner | Provided medical orders, interviewed regarding fall and wound care assessments. |
| Unit Manager A | Unit Manager | Described fall assessment procedures and communication with physician and family. |
| Maintenance Assistant | Responsible for air mattress setup and inflation. | |
| LVN C | Licensed Vocational Nurse | Described fall assessment and SBAR process. |
| CNA F | Certified Nursing Assistant | Provided care for CR#1 and described family interference with care. |
| CNA G | Certified Nursing Assistant | Described resident skin assessments. |
| LVN B | Licensed Vocational Nurse | Described wound dressing procedures and family interference. |
| LVN J | Licensed Vocational Nurse | Described wound care responsibilities and communication. |
| Charge Nurse A | Charge Nurse | Described wound care nurse location and responsibilities. |
| CNA E | Certified Nursing Assistant | Assisted CR#8 with showers and transfers. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 18, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to immediately notify a resident's representative when the resident had a significant change in condition requiring transfer to the hospital.
Complaint Details
The complaint investigation found that the facility did not notify Resident #1's representative about the resident's fall and hospital transfer on 5/4/2023. The representative confirmed she was not informed until contacted by the hospice nurse days later. Facility staff acknowledged the failure was due to being busy and confirmed policy requires notification. The risk includes inappropriate care and lack of representation for the resident.
Findings
The facility failed to notify Resident #1's representative about her fall and transfer to the hospital on 5/4/2023, which could place residents at risk for denial of rights and lack of proper advocacy. Interviews and record reviews confirmed the lack of notification despite facility policy requiring notification of family members upon changes in condition or hospital transfers.
Deficiencies (1)
Failure to immediately notify the resident's representative of a significant change in condition requiring hospital transfer.
Report Facts
Residents reviewed for change of condition: 5
Date of hospital transfer: May 4, 2023
Length of DON employment: 17
RN #B employment duration: 4
RN #A employment duration: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #A | Registered Nurse | Interviewed regarding Resident #1's fall and notification failure; stated she was supposed to notify the resident's representative and DON |
| RN #B | Registered Nurse | Interviewed about facility policy and failure to notify Resident #1's representative; worked 4 months at facility |
| DON | Director of Nursing | Oversees facility operations; interviewed about notification policies and staff oversight; employed 17 days |
| Hospice Nurse | Interviewed about notification to Resident #1's representative; called representative days after hospital transfer |
Inspection Report
Routine
Deficiencies: 1
Date: Apr 11, 2023
Visit Reason
The inspection was conducted to assess the facility's infection prevention and control program, specifically related to the storage and handling of respiratory care equipment for residents receiving breathing treatments.
Findings
The facility failed to maintain an infection prevention and control program by not storing Resident #1's nebulizer face mask in a sanitary manner, leaving it uncovered on a bedside table next to dried food crumbs, which posed a risk of cross-contamination and potential health complications. Nursing staff were educated on proper procedures but failed to follow them, and the facility's infection control policy did not address sanitary storage conditions for nebulizer face masks.
Deficiencies (1)
Failed to store Resident #1's face mask used for breathing treatment in a sanitary manner to avoid cross-contamination.
Report Facts
Residents reviewed for infection control: 5
Breathing treatment frequency: 5
Date of infection control in-service: 2022
Date of physician chest x-ray order: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Charge Nurse | Set up and removed Resident #1's nebulizer face mask and admitted to leaving the face mask uncovered on the rolling table. |
| Regional Respiratory Therapist | Responsible for educating nursing staff on respiratory care and infection control; confirmed staff were educated on proper face mask storage. | |
| ADON | Assistant Director of Nursing | Oversight responsibility for ensuring face masks were covered and protected from cross-contamination. |
| DON | Director of Nursing | Responsible for overseeing nursing staff and infection control policies; confirmed nursing staff education and rounds to ensure compliance. |
Inspection Report
Routine
Deficiencies: 1
Date: Apr 11, 2023
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, specifically related to the storage and sanitary conditions of face masks used for respiratory care in residents receiving breathing treatments.
Findings
The facility failed to maintain an infection prevention and control program by not storing Resident #1's nebulizer face mask in a sanitary manner, leaving it uncovered on a bedside table next to dried food crumbs, which posed a risk of cross-contamination and potential health complications. Nursing staff were educated on proper procedures but failed to follow them, and the facility's infection control policy did not address sanitary storage of nebulizer face masks.
Deficiencies (1)
Failed to store Resident #1's face mask used for breathing treatment in a sanitary manner to avoid cross-contamination.
Report Facts
Residents reviewed for infection control: 5
Breathing treatment frequency: 5
BIMS score: 14
Dates of care plan initiation and revision: Care plan initiated on 9/15/22 and revised on 1/27/22
Date of last infection control in-service: Last in-service on infection control was 12/22/22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Charge Nurse | Responsible for setting up and removing Resident #1's nebulizer face mask and admitted to placing the face mask uncovered on the rolling table. |
| Regional Respiratory Therapist | Responsible for educating skilled care nursing staff and confirmed nursing staff were educated on proper face mask storage. | |
| ADON | Assistant Director of Nursing | Oversight responsibility for ensuring face masks were covered and protected from cross-contamination. |
| DON | Director of Nursing | Responsible for overseeing nursing staff and infection control policies; confirmed nursing staff education and rounds to ensure compliance. |
Inspection Report
Deficiencies: 1
Date: Feb 15, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with medication administration regulations, specifically to ensure residents were free from significant medication errors related to blood pressure medication administration.
Findings
The facility failed to ensure that blood pressure medications were administered as ordered for one resident (CR#1), resulting in medications being given when they should have been held based on blood pressure readings. This failure posed a risk to all residents receiving blood pressure medications. Interviews and record reviews confirmed multiple instances where medications were not held as ordered, and documentation was lacking to explain these errors.
Deficiencies (1)
Failure to ensure blood pressure medications were administered as ordered, resulting in medication errors for one resident.
Report Facts
Residents reviewed for medication errors: 5
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MA B | Medication Aide | Named in medication error finding related to failure to hold blood pressure medications as ordered |
| ADON | Assistant Director of Nursing | Interviewed regarding nursing staff expectations for blood pressure medication administration |
| DON | Director of Nursing | Interviewed regarding expectations for blood pressure medication administration and staff in-service |
Inspection Report
Routine
Census: 43
Deficiencies: 7
Date: Jun 9, 2022
Visit Reason
Routine inspection of Paradigm at First Colony nursing home to assess compliance with regulatory requirements including care planning, activities of daily living, accident prevention, feeding tube care, medication storage, food safety, and pest control.
Findings
The facility was found deficient in multiple areas including failure to update resident care plans, inadequate assistance with activities of daily living, lack of supervision and safety in smoking areas, improper feeding tube care, unsecured medication storage, failure to document food temperatures, and ineffective pest control in the kitchen.
Deficiencies (7)
Failed to develop and implement a comprehensive person-centered care plan for Resident #16, including failure to update care plan to reflect DNR status.
Failed to provide bathing assistance to Resident #46 for 14 days, risking hygiene neglect.
Failed to ensure adequate supervision and safety in the secure unit smoking area, including lack of ashtray, improper disposal of cigarette butts, and unsupervised smoking by residents.
Failed to provide appropriate G-tube care for Resident #49 for 6 days and did not follow physician's orders for tube care.
Failed to secure central supply room containing drugs and biologicals on the 300 hall, leaving it unattended and unlocked.
Failed to take and document food temperatures for meals as required, risking food-borne illness.
Failed to maintain an effective pest control program in the kitchen, with presence of rodent droppings observed.
Report Facts
Residents on 300 hallway: 43
Days without bathing: 14
Days without G-tube care: 6
Vitamin D bottles: 12
Tylenol bottles: 13
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