Inspection Reports for Paradigm at First Colony

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.

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.

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.

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.

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.

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.

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.

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.

The visit was complaint-related, focusing on privacy violations and staffing posting failures. The complaint was substantiated based on observations, interviews, and record reviews.

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.

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.

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.

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.

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.

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.

The complaint investigation found substantiated deficiencies related to incontinent care and infection control practices affecting Residents #1 and #2.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.