Paradigm at Stevens

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure the assessment accurately reflected the resident's status for 1 resident (resident #11) of 8 residents reviewed for accurate assessments. The facility failed to reflect Resident #11 was administered opioid medication on her quarterly MDS assessment dated [DATE]/2026. This deficient practice could place residents at risk of missed or inaccurate care.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 of 3 residents (Resident # 1) reviewed for oxygen therapy. The facility failed to replace or clean dirty and dusty oxygen filters in Resident #1's oxygen concentrator. These deficient practices could place residents at risk of respiratory infection and difficulty breathing.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete medical records for 1 of 5 residents (Resident #33) reviewed for accurate records.1. The facility failed to obtain signed consents for Valproic Acid (anti-seizure medication) to be used as an antipsychotic for Resident #33. This failure could place residents at risk for inaccurate documentation of clinical records and misuse of medication used as an antipsychotic that could result in diminished quality of care.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 resident (Resident #43) of 2 residents observed for incontinent and catheter care. LVN A failed to change Resident #1's soiled incontinent brief after she completed catheter care. This deficient practice could place residents at risk for cross contamination and infections.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources, are reported immediately but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials, including to the State Survey Agency in accordance with State law through established procedures for 1 of 5 residents (Resident #1) reviewed for abuse, neglect and exploitation. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain comfortable temperature levels for 2 of 5 residents (Residents #1 and #2) reviewed for environment. The facility failed to ensure the temperature in the room shared by Residents #1 and #2 was cooled to a comfortable level in September 2025. This failure could lead to decreased quality of life for residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored in accordance with professional food standards for food service safety for 1 of 2 residents (Resident #1) reviewed for food storage. The facility failed to ensure Resident #1's personal refrigerator was maintained at proper temperature and the food was dated and labeled appropriately for September 2025. This failure could lead to food-borne illness and decreased quality life of residents.

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety from 1 of 1 kitchen and 1 of 1 Resident (Resident #2) reviewed for food sanitation and preparation. 1. [NAME] H failed to remove her gloves, wash her hands and put on clean gloves, after opening a drawer of utensils (dirty surface) and continuing with preparing beef tacos with the same gloved hands (she went from dirty to clean). 2. DA I left 2 pans of cake on the prep table to cool off. She did not cover them. 3. CNA used her bare right hand to give Resident #2 two slices of bread during a lunch meal. These deficient practices could affect any resident and could contribute to the spread of food-borne illnesses.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure resident's care plans were revised by the interdisciplinary team after each assessment for 3 of 7 Residents (Resident #16, Resident #35 and Resident #19 ) whose records were reviewed. 1. Resident #16's Care Plan did not reflect he used one 1/4 bed rail for mobility and transfers. 2. Resident #35's Care Plan did not reflect she had impaired vision and needed optometry care. 3. Resident #19's Care Plan did not reflect she was receiving Depakote Sprinkles Delayed Release as a mood stabilizer. These deficient practices could affect any resident and could result in the inaccuracy of assessments and contribute to residents not receiving care for identified care needs.

Inspectors wroteBased on interview and record review the facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activities professional to provide activities for 42 of 42 residents. The facility did not have a qualified Activities Professional to direct their activities program. This deficient practice could affect any resident and could result in residents not receiving approaches that were individualized to match the skills, abilities, and interests/preferences of each resident.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents received proper treatment to maintain vision; the facility must, if necessary, assist the resident in making appointments, and by arranging for transportation to and from the office of a practitioner specializing in the treatment of vision for 1 of 1 Resident (Resident #35) whose records were reviewed for optometry care. Nursing staff failed to ensure Resident #35 received transportation in order to obtain optometry care as needed for more than 2 months. This deficient practice could affect any resident and contribute to the decline of the resident's vision.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that licensed staff were able to demonstrate the specific competencies and skill sets necessary to care for resident's needs for 3 of 6 nursing staff(CNA C, CNA-E and CNA K) reviewed for competencies. 1. a. CNA C and CNA K failed to use safe technique when transferring Resident #19 from the bed to the wheelchair using a mechanical lift. 2. When CNA D and E mechanically transferred Resident #28 from the bed to the wheelchair on 03/05/2025, CNA E did not hold the spreader bar to prevent the spread bar from hitting the resident's head that was swinging while CNA D was lowering the spread bar to connect it to the sling. These failures could place the residents at risk for avoidable falls and injuries as a result of a fall.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 2 medication rooms (3-side medication room) reviewed for pharmacy services. There were total eighteen (18) syringes of 0.9 % sodium chloride injection for flush 10 milliliters expired on 02/28/2025 found inside 3-side medication room on 03/05/2025. This failure could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 14 residents (Residents #6) reviewed for accommodation of needs. The facility failed to ensure Resident #6's call light was within reach while she was positioned on her bed in her room. This failure could place residents at risk for delay in care and services, and increased risk of falls and injuries.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a clean, comfortable, and homelike environment including a clean bed in good condition for 1 of 1 Resident (Resident #14) whose bed was observed for sanitation. The facility failed to replace Resident #14's mattress which was heavily soiled with urine and the urine stains covered at least 50% of the mattress. This deficient practice could affect any resident and result in dissatisfaction and poor self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect and misappropriation for 1 of 5 staff (housekeeper-F) reviewed for criminal backround checks. The facility administrator and human resources completed checking housekeeper-F's criminal background on 03/06/2025, but the housekeeper was hired to the facility on [DATE]. This failure could place all residents at risk of abuse from facility staff.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the assessment accurately reflected the resident's status for 2 of 7 Residents (Resident #16 and Resident #35) whose records were reviewed. 1. Resident #16's quarterly MDS did not reflect he used one 1/4 bed rail for mobility and transfers. 2. Resident #35's quarterly MDS did not reflect she had impaired vision. This deficient practice could affect any resident and could result in the inaccuracy of assessments and contribute to residents not receiving care for identified care needs.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs that were identified in the comprehensive assessment, and described services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 14 residents (Resident #143) reviewed for care plans. The facility failed to ensure Resident #143's care plan reflected her bowel incontinence and included a care plan regarding how to take care of the resident's bowel incontinence. These deficient practices could place residents at risk for not receiving proper care and services due to inaccurate care plans.

Inspectors wroteBased on the observations, interviews, and record review, the facility failed to ensure that the resident's environment remained free of accidents and hazards as was possible and each resident received adequate supervision to prevent accidents for 2 of 2 (Resident #19 and Resident #28) reviewed for mechanical transfers. 1. a. CNA K and CNA C failed to use safe technique when transferring Resident #19 from the bed to the wheelchair using a mechanical lift. b. Nursing staff failed to ensure a floor mat was at Resident #19's bedside while she was in bed. 2. When CNA-D and CNA E mechanically transferred Resident #28 from the bed to the wheelchair on 03/05/2025, CNA-E did not hold the spreader bar to prevent the spread bar from hitting the resident's head that was swinging while CNA-D was lowering the spread bar to connect it to the sling. [...]

Inspectors wroteBased on observations, interviews, 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 and to restore continence to the extent possible for 2 of 2 residents (Resident #11 and #143) reviewed for incontinence care. 1. When CNA-C was providing incontinent care to Resident #11 on 03/05/2025, CNA-F did not clean the resident's suprapubic area (the area of the abdomen located below the umbilical region). 2. When CNA-B was providing incontinent care to Resident #143 on 03/06/2025, CNA-G did not separate and clean the resident's labia area. These failures could place residents who required incontinence care at risk for cross contamination and the development of new or worsening urinary tract infections.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan for 2 of 2 Resident (Resident #16, Resident # 13) whose records were reviewed for oxygen therapy. 1. Nursing staff failed to ensure Resident #16's oxygen concentrator filter was clean while he was receiving oxygen via nasal cannula. 2. Resident #13's nebulizer mask was observed on the resident's dresser on 03/04/2025, and it was not covered in a plastic bag when it was not used. This deficient practice could affect any resident receiving oxygen therapy and could cause the resident to develop an upper respiratory infection.

Inspectors wroteBased on observation, interview and record review the facility failed to assess the resident for risk of entrapment from bed rails prior to installation; to review the risks and benefits of bed rails with the resident and obtain informed consent prior to installation for 1 of 3 Residents (Resident #16) who were reviewed for bed rail use. Nursing staff failed to take the necessary steps prior to allowing Resident #16 to use a bed rail; complete an assessment; attempt the use of alternatives; review risks vs benefits; and to obtain a consent. These deficient practices could affect the residents who used a bed rail and could contribute to avoidable accidents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments for 1 of 2 medication rooms (the 4-side medication room) and 1 of 3 medication carts (the medication aide cart) review for storage and medication carts. 1. The narcotic box located inside a refrigerator in the 4-side medication room was not affixed permanently to the refrigerator, and there were total 12 capsules of Resident #144's Dronabinol 5 mg inside the narcotic box. 2. There were brand new and unopened two eye drop bottles of Latanoprost 0.005% ophthalmic solution stored inside medication aide cart at the room temperature, but the label of the two eye drop bottles said Keep refrigerator unopened. Store opened at room temperature. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records that were complete and accurately documented for 1 (Resident #7) of 14 residents reviewed for clinical records, in that: Resident #7's psychiatric provider indicated the resident had Depakote one tablet 125 mg two times a day for mood disorder, but the facility made an entry in the order incorrectly by Depakote one tablet 125 mg two times a day for dementia. These deficient practices could result in in errors in care and treatment.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public on 1 of 14 residents (Resident #31) reviewed for environmental concerns. There was a hole sized width 20 cm and length 3 cm on Resident #31's bathroom door in the resident's room. These failures could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections and handle, store, process, and transport linens to prevent the spread of infection for 2 of 47 residents (Resident #1 and Resident #2) reviewed for infection control. The facility failed to report to the State Survey Agency (HHSC) an outbreak of scabies infection. These failures could place residents at risk of a delay of identification infectious outbreaks and lack of timely follow-up on recommended interventions to prevent harm, or impairment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice for 1 of 7 (Resident #1) reviewed for respiratory care. Resident #1's oxygen tubing, humidifier and nasal canula were not replaced within the facility's time frame for replacement (every Wednesday during the night shift (10:00 pm to 6:00 am). This failure could affect residents administered oxygen and could lead to infections if the tubing, humidifier and canula are not cleaned/ or replaced as common practice in the facility and per facility policy.

Inspectors wroteBased on observation, record review and interview the facility failed to provide the services of a Registered Nurse to serve as the director of nursing on a full-time basis for 1 of 1 facility reviewed for nursing services, in that: The facility failed designate a registered nurse to serve as the Director of Nursing on a full time basis on [DATE]th and 13th 2024. This failure affected residents who resided in the facility by putting them at risk of poor nursing care.

Inspectors wroteBased on interview, and record review, the facility failed to maintain medical records, in accordance with accepted professional standards and practices, which are complete; and accurately documented for 1 of 7 residents (Resident #1) reviewed for completeness and accuracy: Resident #1 was prescribed PRN (as needed) O2 and the April and May 2024 MARs did not capture or document the resident's nebulizer, humidifier, and 02 tubing needed to be changed every seven days per facility's procedure. This failure could result in the facility not documenting in the medical record residents on oxygen therapy not having their O2 nebulizer, humidifier and tubing changed which could cause infections and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide and document sufficient preparation and orientation to ensure safe and orderly transfer or discharge from the facility for 1 of 6 (Resident #1) residents reviewed for transfer or discharge. The facility failed to ensure sufficient resident education was provided to Resident #1, who had a recent AKA, osteomyelitis (serious infection of the bone), midline (venous access device inserted in a deep vein of the arm) and an order for IV antibiotics/wound care, and his RP when discharged home from the facility on 5/13/24. 1. Facility did not arrange home health services for Resident #1's wound care, ordered 5/10/24, and IV medication administration, ordered 5/11/24, when the resident was discharged on 5/13/24. 2. Facility staff did not provide Resident #1's RP with proper education related to IV antibiotic administration. 3. [...]

Inspectors wroteBased on record review and interview the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect and exploitation for 1 of 4 residents (Resident #1) reviewed for abuse, in that; The facility failed to develop and implement a written abuse policy for reporting abuse within 2 hours to the State Survey Agency (HHSC) which resulted in a failure to report an allegation of abuse made by Resident #1 until surveyor intervention. This failure could place all residents at risk for potential abuse due to unreported allegations of abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all allegations involving abuse, neglect, and misappropriation were reported immediately, but no later than 2 hours after the allegation of abuse to the State Survey Agency for 1 of 4 residents (Resident #1) reviewed for abuse, in that: The facility failed to report to the State Survey Agency (HHSC) allegations of abuse made by Resident #1 immediately or within 2 hours. This failure could place all residents at increased risk for potential abuse due to unreported allegations of abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. The facility failed to ensure dietary staff with facilal hair, were wearing beard restraints. These failures could place resident who received meals and/or snacks from the kitchen at risk for food borne illness.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health and safety of the resident and or other residents for 2 (Resident #16 and #44) of 8 residents observed for accommodation of needs. 1. Resident #16's call light was not placed within reach. 2. Resident #44's call light was not placed within reach. This deficient practice could affect residents who require assistance with care and could result in an emergent need not being addressed.

Inspectors wroteBased on interview and record review, the facility failed to ensure assessments accurately reflected the resident's status for 1 of 8 Residents (Resident #12) whose MDS records were reviewed for accuracy. Resident #12's Quarterly MDS assessment dated [DATE] incorrectly documented the resident had received tube feedings while a resident at the facility. This failure could place residents at risk for inadequate care due to inaccurate assessments.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #18) of 8 residents reviewed for care plans. Resident #18's care plan did not reflect that she required supervision when she smoked. This deficient practice could affect residents who required supervision and could result in an accident or harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 4 residents (Residents #1 and #20) reviewed for incontinent care. While providing incontinent care for Resident #98, CNA E did not return Resident #1's foreskin to the normal position. This deficient practice could place residents at-risk for infection, paraphimosis (urologic emergency in uncircumcised males) and skin break down due to improper care practices.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents goals and preferences for 1 (Resident #16) of 2 residents reviewed for oxygen therapy. LVN B turned off Resident #16's oxygen concentrator and did not return to turn it back on. This deficient practice could affect residents on oxygen therapy and could result in low or high oxygen levels in the blood and cause respiratory distress.