Paradigm at Faith Memorial

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment for 1 of 19 residents (Resident # 11) reviewed for care plan revision. --Resident # 11's care plan was not revised for skin condition. This failure placed residents at risk of not receiving proper individualized care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure drugs and biologicals were stored in accordance with currently accepted professional principles for 1 of 1 medication fridges reviewed for storage of drugs. The facility failed to ensure that all medications were not expired. This failure could place residents at risk of receiving expired medications and not receiving the full therapeutic doses and effects of those medications. Observation on 4/21/2026 at 2:47 p.m. of the Station 1 Medication Room revealed 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. During interview on 4/21/2026 at 2:47 p.m., the DON answered correct when asked if medications were to be removed from the fridge when they expired. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to report an allegation of abuse to the state survey agency within 5-working days of the incident for 1 (Residence #1) of 3 residents reviewed for abuse. On 01/01/2026 Certified Nursing Aide (CNA) A failed to report verbal abuse to abuse coordinated immediately or within 2-hours that CNA B had cursed and threatened Resident #1 on 12/31/2025. These deficient practices could place residents at risk for abuse, neglect, exploitation, and/or mistreatment.

Inspectors wroteBased on interview and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of diseases for 1 of 3 Residents (Residents #2) and 3 of 4 staff (LVN B, MA A, and PTA A) reviewed for infection control. LVN B, MA A, and PTA A failed to document and/or report feces found on Resident #2's mouth/teeth, face, beard, hand, fingernails, and pillow sheet to the resident's nurse. These failures could place residents at risk for spread of infection and cross contamination.

Inspectors wroteBased on interviews, and record review, the facility failed to ensure each resident was free from abuse for 1 of 3 residents (Resident #1) reviewed for abuse in that: The facility failed to ensure each resident was free from verbal abuse when CNA A cussed at and threatened Resident #1 on 12/31/2025. These failures placed residents, who resided in the facility, at risk of abuse, and mental anguish and fearfulness.

Inspectors wroteBased on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 3 residents (Resident #2) reviewed for care plans. The facility failed to ensure a comprehensive care plan for a behavior of resident placing his hand in him soiled brief with bowel movement and placing his hand in his mouth was implemented for Resident #2 This failure placed residents at risk of not receiving care and treatment to meet the resident's physical, mental, and psychosocial needs.

Inspectors wroteBased on interview, and record review, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Based on interview, and record review, the facility failed to notify the resident's physician, as applicable, promptly after a significant change in the mental or physical condition of a resident who had mental illness or intellectual disability for 1 of 3 residents (Residents #1) reviewed for Significant Change Notification. The facility failed to notify the medical doctor (MD) after Resident #2 was found with feces in/on his mouth. The facility failed to document Resident #2 having feces in/on his mouth. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records on each resident that are accurately documented for 1 (Resident #1) of 9 residents reviewed for resident records. Resident #1's Medication Administration Record showed medications were administered on 11/6/25 and 11/8/25 after Resident #1 left the faciity on [DATE]. The failure could place residents at risk of an inaccurate medical record.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 2 (Resident #1 and Resident #2) of 3 residents reviewed for catheter care. The facility failed to ensure Resident #1 and #2 received urinary catheter changes as ordered every month. This failure caused Resident #1 emotional distress and Resident #2 experienced a urinary tract infection. Resident #1 reported anxiety regarding the urinary catheter not being changed and Resident #2 was prescribed oral antibiotics on 10/13/25 for urinary tract infection. This failure could place other residents with catheters at risk of infection or emotional distress.

Inspectors wroteBased observation, interview, and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for 1 (Resident #1) of 11 residents reviewed for pharmaceutical services. The facility failed to ensure Resident #1 received Acetaminophen-Codeine Tablet 300-30 mg as ordered as evidenced by gaps in administration. This failure could place the residents at risk of not receiving medications as ordered by the physician and unmanaged pain.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 out of 21 residents (Resident #1) reviewed for adequate supervision. The facility failed to provide adequate supervision to Resident #1 who had a diagnosis of vascular dementia and eloped from the facility to a tire shop two blocks away from the facility for at least an hour. Resident #1 was severey cognitively impaired, which put her at increased risk of injury. An IJ for Past Non-Compliance was called on 2/20/25 at 3:18pm with the facility Administrator and DON. The noncompliance was identified as Past Non-Compliant. The IJ began on 12/2/24 and ended on 12/5/24. [...]

Inspectors wroteBased on interviews and record review, the facility failed to utilize the services of a registered nurse for at least eight consecutive hours per day, seven days per week for 4 days out of 30 days (9/1/24 (Sunday), 9/14/24 (Saturday), 9/15/24 (Sunday), and 9/29/24() reviewed for nursing services. The facility failed to ensure a registered nurse was scheduled for eight consecutive hours per day, seven days per week on the following dates: 9/1/24 (Sunday), 9/14/24 (Saturday), 9/15/24 (Sunday), and 9/29/24 (Sunday). This deficient practice could place residents at risk of not receiving adequate care by not having staff available with the ability to perform assessments as needed.

Inspectors wroteBased on Record review and interview, the facility failed to transmit encoded, accurate, and complete MDS data to the CMS System within 14 days after a facility completes the resident's assessment for 2 (Resident #36, and CR #81) of 18 residents reviewed for MDS transmission, in that: -The facility failed to transmit a completed admission MDS assessment for Resident #36 within 14 days of completion. -The facility failed to complete and transmit a Discharge MDS assessment for CR #81 within 14 days after completion. These failures could place residents at-risk of not having their assessment and care plan completed timely, which could result in denial of services and or payment for services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist residents in obtaining routine dental care for 1 of 8 residents (Resident #14) reviewed for dental services The facility failed to ensure Resident #14 was referred to the dentist after complaining of tooth pain. The failure could place residents at risk of pain and decline in health.

Inspectors wroteBased on observation, interview, and record review the facility failed to store food in accordance with professional standards for food service safety in the facility's one of one only kitchen reviewed for kitchen sanitation. -The facility failed to label, and date left over foods items in 3 of 3 coolers in the kitchen. -The facility failed to ensure that food brought from home by staff were, label. dated and was stored in a designated refrigerator outside the kitchen. These failures could place residents at risk for food-borne illness and food contamination.

Inspectors wroteBased on interviews and records reviewed, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 (Resident #1) of 8 residents reviewed for incontinent care. -The facility failed to replace Resident #1's foley catheter's drainage bag after it was removed by the resident. This failure could place residents at risk for urinary tract infections.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of five residents reviewed for quality of care. The facility failed to utilize emergency transport after Resident #1 had an unwitnessed fall which resulted in a subdural hematoma and 2.5-hour delay in care. Resident #1 was sent to the hospital and placed in the ICU. An Immediate Jeopardy (IJ) situation was identified on 7/26/24 at 6:10 PM. While the IJ was removed on 07/28/24, the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that the resident and/or representative had the right to participate in the development and implementation of his or her person-centered plan of care, and to ensure that the planning process facilitated the inclusion of the resident and/or representative for one (Resident #42) of six residents reviewed for participation in care plan. The facility failed to ensure the IDT included Resident #42's RP, in the review of his comprehensive assessment and were able to discuss his individualized care needs for services to include his need for medical and nursing care, medications, therapy, psychological, and dietary needs. The failure could affect residents by placing them at risk for not receiving adequate or individualized care.

Inspectors wroteBased on interview and record review the facility failed to complete and transmit an MDS for 2 of 3 (CR #31& CR #95) residents reviewed for closed records. 1 The facility failed to complete and transmit a discharge MDS for Resident #31 2 The facility failed to complete and transmit admission and discharge MDS for CR #95 These failures could place residents at risk of facility not providing complete and specific information for payment and quality of measure purposes.

Inspectors wroteBased on interview and record review the facility failed to accurately assess each resident's cognitive status for 2 of 18 residents (Resident #28, #42), reviewed for assessment accuracy. - The facility failed to accurately assess and document Resident #42's cognitive patterns on two different consecutive MDS assessments, and Resident # 28's Annual MDS reflected he had all his natural teeth. These failures could place residents at risk of not having accurate assessments, which could compromise their plan of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised by the Interdisciplinary team after each assessment for 1 of 18 residents reviewed for care plan accuracy (Resident # 20). --Resident #20 did not have a care plan for Hospice services, which began 6/20/23. This failure placed residents at risk of not receiving care and services according to their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection for 1 (Resident #36) of 5 resident reviewed for infection control. The facility failed to ensure that the Wound Care Nurse implemented appropriate use of PPE and transmission-based precautions prior to enter and exiting Resident #36 room. Resident #36 was ordered Contact Isolation for MRSA of the right foot wound. This failure has the potential to affect residents by placing them at an increased and unnecessary risk of exposure to communicable diseases and infections. Findings Included: Record review of Resident #36's face sheet dated 01/10/2024 revealed resident was admitted to the facility on [DATE], age [AGE] years old. [...]