Paonia Care and Rehabilitation Center

Inspectors wroteBased on record review and interviews, the facility failed to ensure that residents were free from significant medication errors for one (#4) of three residents reviewed for medication errors out of 11 sample residents. Resident #4, who had a diagnosis of seizures, was admitted to the facility from home on 4/27/26 for a five-day respite stay. The resident had physician's orders for levetiracetam (a medication used to treat seizures) to be administered two times per day related to her seizures. The resident was scheduled to receive the levetiracetam medication between 3:00 p.m. and 6:00 p.m., per her home medication regimen. However, the medication orders were not obtained until 4:00 p.m. (over five hours after the resident was admitted to the facility). [...]

Inspectors wroteBased on record review and interviews, the facility failed to revise and implement an effective discharge plan for one (#4) of one resident reviewed for discharge planning out of 11 sample residents. Specifically, the facility failed to complete a discharge summary for Resident #4.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that one (#42) of 10 residents reviewed for freedom from involuntary seclusion out of 27 sample residents was provided the least restrictive environment and was not placed on a secured locked unit without an evaluation, assessment, justification, or documentation. Resident #42 was cognitively intact and had no history of wandering. On 7/13/25, following an incident in which she attempted to leave the facility to walk to a nearby store, staff redirected Resident #42 to a room on the secured locked memory care unit. Facility documentation revealed no physician's order, no completed assessment justifying locked secured unit placement, no evidence the secured placement was the least restrictive alternative and no interdisciplinary team (IDT) review before or immediately after the move. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure five (#40, #28, #45, #5 and #43) of seven residents reviewed for abuse out of 27 sample residents were kept free from abuse. Specially, the facility failed to:-Protect Resident #40 from physical abuse by Resident #45;-Protect Resident #28 from physical abuse by Resident #45; -Protect Resident #28 and Resident #45 from physical abuse by each other;-Protect Resident #5 from physical abuse by Resident #28; and, -Protect Resident #43 from physical abuse by Resident #32.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that one (#28) of ten residents out of 27 sample residents were free from chemical restraint and were receiving the least restrictive approach for their needs. Specifically, for Resident #28, the facility failed to provide adequate documentation to justify the addition of new psychotropic medications, the increase in dosage of psychotropic medications and/or the continued use of psychotropic medications.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide residents who were unable to carry out activities of daily living (ADLs) the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for one (#1) of three residents reviewed out of 27 sample residents. Specifically the facility failed to -Offer repositioning to Resident #1, and;-Provide assistance with toileting for Resident #1.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#8) of two residents reviewed for respiratory care out of 27 sample residents were provided respiratory care consistent with professional standards of practice. Specifically, the facility failed to ensure cleaning and proper care of Resident #8's CPAP (continuous positive airway pressure) machine according to manufacturer's instructions and per physician's orders.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that a resident who was a trauma survivor received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for one (#42) of five residents with a documented history of trauma out of 27 sample residents. Specifically, the facility failed to identify and create a person-centered individualized care plan that addressed Resident #42's past history of trauma, and/or triggers which may cause re-traumatization and train staff on the residents trauma and triggers.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to identify and address the behavioral health care needs of two (#45 and #32) of 10 residents out of 27 sample residents. Specifically, the facility failed to:-Develop individualized interventions related to psychotropic medications for Resident #45 and Resident #32; and,-Consistently document the non-pharmacological interventions that were attempted and/or effective for Resident #45 and Resident #32's behaviors.

Inspectors wroteBased on observations and interviews, the facility failed to ensure infection prevention and control programs (IPCP) were maintained and followed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on two of three units. Specifically, the facility failed to: -Ensure staff performed hand hygiene prior to providing wound care for Resident #19;-Ensure staff followed appropriate infection control guidelines for handling of wound care supplies for Resident #19; and,-Ensure staff wore the appropriate personal protective equipment (PPE) when providing incontinence care for Resident #6, who was on enhanced barrier precautions (EBP) for having an indwelling urinary catheter.

Inspectors wroteBased on observations, record review and interviews, the facility failed to develop an antibiotic stewardship program that promotes the appropriate use of antibiotics and includes a system of monitoring to improve resident outcomes and reduce antibiotic resistance for one (#6) of two residents out of 27 sample residents. Specifically, the facility failed to ensure clinical signs and symptoms of an infection were identified and/or culture results were obtained prior to the administration of antibiotics for Resident #6.

Inspectors wroteBased on record review and interviews, the facility failed to implement policies and procedures related to pneumococcal immunizations for two (#19 and #7) of five residents reviewed for immunizations out of 27 sample residents. Specifically, the facility failed to offer the pneumonia vaccine to Resident #19 and Resident #7.

Inspectors wroteBased on record review and interviews, the facility failed to implement policies and procedures related to COVID-19 immunizations for two (#19 and #7) of five residents reviewed for immunizations out of 27 sample residents. Specifically, the facility failed to offer the COVID-19 vaccine was offered to Resident #19 and Resident #7.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure two (#2 and #3) out of 10 residents reviewed for abuse were free from sexual abuse out of 13 sample residents. Specifically, the facility failed to protect Resident #2 and Resident #3 from sexual abuse by Resident #1.

Inspectors wroteBased on record review, and observations, the facility failed to ensure seven (#6, #15, #14, #18, #33, #8, and #26) of nine residents with a dysphasia diagnosis out of 35 sample residents received food and fluids prepared in a form designed to meet their needs per physician orders and the residents' care plans. Observations of the tray line and dining room service on 2/28 and 2/29/24 revealed the facility failed to follow the residents' therapeutic diet orders. Seven out of seven residents, all with a dysphagia diagnosis, failed to receive a mechanically altered diet that required a change in texture (mechanical soft) as ordered and care planned. One of the seven residents failed to receive thickened liquid. [...]

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure one (#29) of three residents reviewed for nutrition received the care and services necessary to meet their nutritional needs and maintain their highest physical well-being level out of 35 sample residents. Resident #29 was at nutritional risk with a diagnosis of dementia. Interventions were implemented by the registered dietitian due to the resident's nutritional risk and history of weight loss, however, these interventions were not consistently evaluated for effectiveness. Observations during the survey revealed the resident's intake of nutritional supplements were not accurately documented. When the resident sustained a significant weight loss from 1/2/24 to 2/2/24, the intervention of offering fortified foods was not added until 20 days later. [...]

Inspectors wroteBased on record review and interviews, the facility failed to employ dietary staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service for 38 census residents. Specifically, the facility failed to: -Provide dietary competencies and skill tests to ensure staff could carry out the functions of the food and nutrition service according to professional standards of practice; and -Ensure the dietary supervisor was trained and certified as a dietary manager. Cross-reference F803 for dietary menus to meet residents' needs. Cross-reference F804 for food palatability and proper temperature. Cross-reference F805 for food prepared in a form to meet residents' needs. Cross-reference F806 for food prepared to accommodate residents' allergies. Cross-reference F812 for failure to prepare and serve food in a sanitary manner.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure menus met the needs of residents and were followed. Specifically, small portions were served to all residents and menu items were omitted without substitutions being made.

Inspectors wroteBased on observations, record review and interviews the facility failed to store, prepare, distribute, and serve food in a sanitary manner. Specifically, the facility failed to ensure: -Cold food items were held at the proper temperature to reduce the potential risk of foodborne illness; -Expired dry goods were disposed of; -Proper hand hygiene was performed during meal service; -Kitchen refrigerators were held at the appropriate temperature; and, -Food items were labeled with use-by dates.

Inspectors wroteBased on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, food and nutrition services and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to food and nutrition services, quality of care, resident safety and infection control.

Inspectors wroteBased on record review and interviews the facility failed to ensure that personal funds accounts were managed adequately for six (#19, #20, #1, #4, #10 and #138) of six residents out of 35 sample residents. Specifically, the facility failed to -Have signed written authorizations to manage the personal funds accounts for Residents #1, #4, #20, #138 and #19; and, -Have personal funds withdrawal sheets signed to ensure the residents' permission was obtained to withdraw funds from their personal needs accounts for Residents #1, #10, #4 and #138.

Inspectors wroteBased on record review and interviews, the facility failed to ensure money from personal funds accounts was managed accurately for two (#138 and #4) out of seven residents reviewed for personal funds accounts out of 35 sample residents. Specifically, the facility failed to: -Were dispersed within 30 days after discharge for Resident #138; and, -Notify Resident #4, who was Medicaid funded, or his legal representative when the resident's personal funds account reached $200.00 less than the eligibility resource limit.

Inspectors wroteBased on observations and interviews, the facility failed to provide a functional, sanitary and comfortable environment for residents on two of two units. Specifically, the facility failed to: -Provide linens to residents; and, -Mitigate unpleasant odors throughout the facility; and, -Ensure ceiling fans in resident areas were working.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to provide person-centered, individualized activities to meet the psychosocial needs of five (#1, #28, #20, #29 and #10) out of eight residents reviewed for activities out of 35 sample residents. Specifically, the facility failed to: -Create a program of Spanish-language activities for Resident #10 in order to support his physical, cognitive, social and emotional health; -Provide person-centered activities to accommodate Resident #28's preferences; -Create a program of activities that were accessible for Resident #20 with visual impairment; and, -Provide meaningful, engaging activities for Resident #1 and Resident #29.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the activities program was directed by a qualified professional. Specifically, the facility failed to employ a qualified activities director in order to provide a program of activities for residents requiring activity and recreational support.

Inspectors wroteBased on record review, observations and interviews, the facility failed to ensure an environment free from risk of accidents and hazardous situations for four (#1, #27, #25 and #6) of four residents reviewed for accident hazards out of 35 sample residents. Specifically, the facility failed to: -Implement appropriate safety devices when assisting Resident #1 and Resident #25 in their wheelchairs; -Safely transfer Resident #27 and Resident #1 using an appropriate transfer device; and, -Ensure speech therapy recommendations were implemented for Resident #6.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the medication error rate was less than five percent. Specifically, the facility had a medication error rate of 17.86%, which was five errors out of 28 opportunities for error.

Inspectors wroteBased on observations, interviews and record review, the facility failed to consistently serve food that was palatable, attractive, and at the appropriate temperature. Specifically, the facility failed to: -Ensure food was palatable and attractive when delivered to residents; and, -Ensure food was served at the appropriate temperature.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection on two of two units. Specifically, the facility failed to: -Ensure staff followed proper hand hygiene procedures when moving from task to task; -Ensure frequently touched surfaces were cleaned; and, -Ensure surface disinfectant times were adhered to for disinfecting products by all staff.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents can communicate in their native language for one (#10) resident reviewed for language services out of 35 sample residents. Specifically, the facility failed to provide a system for Resident #10 to receive medical information in his native language.

Inspectors wroteBased on record review and interviews the facility failed to permit a resident to return to the facility after going to the hospital for one (#137) of two residents reviewed for discharge out of 35 sample residents. Specifically, the facility failed to allow Resident #137 to return to the facility once he was medically cleared by the hospital to return.

Inspectors wroteBased on record review and interviews, the facility failed to develop a comprehensive care plan for services that were to be provided in order to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being for four (#3, #4, #5 and #6) residents of four residents reviewed for care planning out of 35 sample residents. Specifically, the facility failed to: -Develop a bathing care plan focus for Resident #4; -Develop a nutrition care plan focus for Resident #3; -Develop a care plan to include speech therapy interventions at meals for Resident #6; and, -Develop an oral hygiene assistance care plan focus for Resident #5.

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement an effective discharge plan that focused on each resident's goals and involved the resident in the development of the discharge plan for one (#36) of two residents reviewed for discharge planning out of 35 sample residents. Specifically, the facility failed to: -Ensure Resident #6's discharge planning needs were identified and documented in order to develop an appropriate discharge plan; and, -Involve the interdisciplinary team in the ongoing discharge process.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide assistance with activities of daily living (ADL) for two (#5 and #10) of two residents reviewed for ADLs out of 35 sample residents. Specifically, the facility failed to: Provide set-up teeth brushing assistance for Resident #5; and, Provide set-up bathing assistance for Resident #10.

Inspectors wroteBased on observation and interviews, the facility failed to ensure residents were free from significant medication errors for one (#19) of 11 residents reviewed for medication errors out of 35 sample residents. Specifically, the facility failed to ensure Resident #19 was administered insulin according to the manufacturer's guidelines.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide food that accommodated resident allergies, intolerances, and preferences for one (#20) of three residents reviewed for dietary preferences out of 35 sample residents. Specifically, the facility failed to provide meals and snacks according to Resident #20's lactose and gluten allergy.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure information was discussed and posted on how to file a complaint with the State Agency with six residents who regularly attend monthly resident council meetings (#19, #32, #22, #21, #24 and #9). Failure to post the information had the potential to affect all residents who were not able to find this resource. Specifically, the facility failed to have the required posted information written in a readable font size and placed in an area that had ease of access for the residents.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide adequate supervision and assistance to prevent accidents for two (#186 and #13) of five residents reviewed out of 19 sample residents. Specifically, Resident #186 had three falls within one week of her admission. However, the facility failed to assess and implement safe and effective approaches to prevent falls other than seatbelts and alarms, creating further accident potential when a gait belt was applied to tie her to her chair for two days. (Cross-reference F604, Restraints.) Resident #13, who frequently rejected care, suffered two skin tears during a shower after she became combative with staff.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to ensure one (#1) of two residents reviewed for nutrition/hydration maintained acceptable parameters of nutritional status to avoid unintended weight loss out of 19 sample residents. Specifically, the facility failed to prevent significant weight loss and implement physician's orders related to Resident #1's weight decline. Resident #1 was identified to have a potential nutritional deficit and had actual significant weight loss. New interventions were not put in place after the identified weight loss and current interventions were not offered as ordered to help prevent the potential additional weight loss. Resident #1 had a diagnosis of dementia and relied on staff to meet her nutritional needs. Resident #1 lost more than 14% of her weight in six months. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns were implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life, and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and implement an effective system to identify facility concerns or address need for quality improvement in their QAPI program.

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents were free from abuse for six (#18, #10, #33, #7, #1, #22) of nine residents reviewed for abuse out of 19 sample residents. Specifically, the facility failed to ensure residents were free from resident-to-resident abuse.

Inspectors wroteBased on record review and staff interviews, the facility failed to report allegations of abuse to the State Survey and Certification Agency in accordance with State law involving seven (#1, #7 #10, #18, #22, #33, and #35) of nine residents reviewed for abuse out of 19 sample residents. Specifically, the facility failed to timely report allegations of: -Resident to resident physical abuse for Residents #1, #7, #10, #18, #22, #33 and #35; and, -Staff to resident physical abuse for Resident #35. Cross-reference F600, failure to protect residents' rights to be free from abuse.

Inspectors wroteVII. Resident #18 A. Resident status Resident #18, age [AGE], was admitted [DATE]. According to the November 2022 computerized physician orders (CPO), diagnoses included unspecified dementia, anxiety disorder, and bipolar disorder with psychotic features. According to the 8/30/22 minimum date set (MDS), the resident was unable to complete the brief interview for mental status exam (BIMS). The resident had memory problems with both short and long term memory. B. Record review A behavior progress note dated 8/18/22 showed a monthly review of psychotropic medications related to the resident. Target behaviors being monitored were delusional ideations, agitation with not receiving immediate gratification, sudden mood changes, temper tantrums, screaming uncontrollably, aggressive behaviors towards others, physical acts of aggression, negative statements, and weeping/crying. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure residents were free from unnecessary restraints for one (#186) of three residents out of 19 sample residents. Specifically, the facility failed to use a position change alarm restraint appropriately, to use an appropriately approved type of restraint, attempt to use the least restrictive alternative restraint, and to follow the physician orders for appropriate use of a restraint, for Resident #186. Since the resident's admission on [DATE], the facility had implemented personal alarms to the resident's wheelchair and bed, a gait belt that was inappropriately used to restrain Resident #816 to her wheelchair, and an alarming seat belt to her wheelchair. Cross-reference F689, failure to prevent accidents and/or hazardous conditions.

Inspectors wroteBased on interviews and record review, the facility failed to ensure allegations of abuse were investigated for three (#25, #13, and #35) of nine residents reviewed for abuse allegations of 19 sample residents. Specifically, the facility failed to: -Conduct a comprehensive investigation into allegations of abuse for Residents #25 and #13; and, -Conduct a comprehensive investigation into Resident #35's skin tears obtained during bathing.

Inspectors wroteBased on interviews and record review, the facility failed to ensure therapy and restorative services to maintain highest practicable level of functioning for three (#25, #186, #7) of three residents reviewed for rehab and restorative services of 19 sample residents. Specifically, the facility failed to ensure services to maintain residents' highest practicable levels of functioning.