Paradigm at Sweeny

Inspectors wroteBased on interviews and record review the facility failed to ensure a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (CR#1) of 7 residents reviewed. The facility failed to initiate wound preventative measures on [DATE] when CR#1 readmitted to the facility leading to infection and hospitalization. The facility failed to assess and recognize a change in condition and initiate wound preventative measures of [DATE] when the facility became aware that CR#1 had redness on her sacrum area during weekly skin observation leading to infection and hospitalization. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the Administrator on [DATE] at 7:21p.m. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to ensure a resident, with or without an indwelling catheter, receives the appropriate care and services to prevent urinary tract infections to the extent possible for 1 of 3 (Resident #1) reviewed for incontinent care. -CNA did not remove his contaminated gloves nor performed hand hygiene while providing incontinent care for Resident #1; placing the resident at risk for UTI infection due to the incorrect incontinent care procedure. This failure could place residents at risk for UTI infections or hospitalizations. Findings Included:Record review of face sheet for Resident # 1, dated 5/11/2026, revealed a 73- year-old male admitted to the facility on [DATE] with the following diagnosis: [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to prevent the development and transmission of disease and infection for one (Resident # 1) of three residents reviewed for infection control. CNA A, on 5/11/2026, did not remove his contaminated gloves nor performed hand hygiene after touching multiple surfaces prior to and after incontinent care to Resident # 1. This failure could place residents at risk for spread of infection and cross contamination. Findings Included:Record review of face sheet for Resident # 1, dated 5/11/2026, revealed a 73- year-old male admitted to the facility on [DATE] with the following diagnosis: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure two residents (Resident #59 and Resident #60) of five residents reviewed for abuse and neglect were free from abuse. The facility failed to address inappropriate sexual behavior between Resident #59 and Resident #60. Resident #59 had a diagnosis which included Dementia and Resident #60 had a diagnosis which included Alzheimers. The facility failed to immediately implement the Psychology NP's recommendation to move Resident #60 off of the unit. An Immediate Jeopardy (IJ) was identified on 6/14/2025. The IJ template was provided to the facility on 6/14/2025 at 3:35 p.m. While the IJ was removed on 6/17/2025, the facility remained out of compliance at a scope of pattern with the severity level at a potential for more than minimal harm that is not immediate jeopardy, because all staff had not been trained. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care that included measurable objectives and timeframes to meet the residents' medical, nursing, and mental and psychological needs that are identified in the comprehensive assessment for 3 residents (Resident #31, Resident #59, and Resident #60) of 8 residents reviewed for care plans. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident's environment remained free of accident hazards for 1 of 6 residents (Resident #31) reviewed for accident hazards. The facility failed to adequately supervise Resident #31 when she ingested plastic wrap from a container while being monitored by CMA H during dining. An IJ was identified on 07/03/35 at 1:22 PM. The IJ template was provided to the facility on [DATE] at 1:22 PM. While the IJ was removed on 07/04/25, the facility remained out of compliance at a scope of isolated and a severity of no actual harm with potential for more than minimal harm because all staff had not been trained on accidents and supervision. This failure could place residents at risk for injury, harm, and impairment.

Inspectors wroteBased on record review and interview, the facility failed to ensure the notices to residents was provided when changes in coverage were made to services covered by Medicare/Medicaid for 3 of 3 residents (Resident #1, Resident #6, and Resident #43) reviewed for resident rights. -The facility failed to ensure Resident #1, Resident #6 and Resident #43 was given a Notice of Medicare NON-Coverage (resident who is not covered on a Medicare Part A skilled nursing stay) and or Beneficiary Notice CMS form 10055 (Notice of Medicare Non-Coverage). This failure could place residents, or their representatives at risk for not being fully informed about services covered by Medicare Part A and not being aware of changes to provided services.

Inspectors wroteBased on observations, interviews, 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 reviewed for storage, preparation and sanitation. -The facility failed to label and date gravy and milk stored in the walk-in refrigerator. -The facility failed to label and date Gelatin stored in the dry storage. -The facility failed to discard expired cooked food from the walk-in refrigerator. -The facility failed to discard juice thickener, with a best used by date of 04/16/25, from the dry storage. These failures could place residents who received meals and/or snacks from the kitchen at risk for food-borne illness and food contamination if consumed.

Inspectors wroteBased on record review and interview, the facility failed to provide and document sufficient preparation and orientation of resident representative to ensure safe and orderly transfer or discharge from the facility for 1 of 1 resident (Resident #1) reviewed for transfer and discharge rights.-The facility failed to notify the resident representative (Office of the State Long-Term Care Ombudsman) of the transfer or discharge with the reasons for the move in writing in a language and manner they understand. -The facility failed to send a copy of the notice of transfer or discharge to the representative of the Office of the State LTC Ombudsman involving Resident #1.-This failure placed residents at risk of not receiving an advocate who can inform them of their options, rights, and the added protection from being inappropriately transferred or discharged .

Inspectors wroteBased on interview and record review the facility failed to implement their written policies and procedures that prohibit and prevent abuse and neglect for 2 of 6 residents (Resident#1 and #2) reviewed for investigating and reporting abuse and neglect. 1. The facility failed to conduct a thorough investigation and report to SSA after Resident #1 was found on the floor, observed with a skin tear and hematoma to the right eyebrow and hematoma to the right check on 5/24/2024, and Resident#1 was unable to provide details on how the incident occurred. 2. The facility failed to conduct a thorough investigation and report to SSA after Resident #2 an a family member of Resdient#2 alleged an incident of abuse on 5/31/2024. These deficient practices could have placed residents at risk for abuse, neglect, exploitation, and or mistreatment. Findings Included: [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure all alleged violations involving abuse and neglect were reported immediately but not later than 24 hours if the events that cause the allegation did not involve abuse and did not result in serious bodily injury to the State Survey Agency (SSA) for 2 of 6 residents (Resident #1 and #2) reviewed for reporting. 1. The facility failed to report an unwitnessed fall to the SSA when Resident #1 was found on the floor, was unable to provide details on how the fall occurred, and staff assessed Resident#1 to have a skin tear and hematoma (bruise) to the right eyebrow and a hematoma to the right check on 05/24/2024. 2. The facility failed to report the allegation of abuse alleged by Resident #2 on 05/31/2024 to the SSA. [...]

Inspectors wroteBased on interview and record review the facility failed to thoroughly investigate and to prevent further potential abuse, neglect, exploitation or mistreatment while the investigation is in process, and failed to ensure corrective action must be taken for 2 of 6 residents (Resident#1 and #2) reviewed for abuse. 1. The facility failed to investigate after Resident #1 was found on the floor, observed with a skin tear and hematoma to the right eyebrow and hematoma to the right check on 5/24/2024, and Resident#1 was unable to provide details on how the incident occurred. 2. The facility failed to report the allegation of abuse alleged by Resident #2 on 5/31/24 to the State Agency. These deficient practices could have placed residents at risk for abuse, neglect, exploitation, and or mistreatment.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 3 of 10 residents (Residents #52, #220, and #15) reviewed for care plans. The facility failed to update Resident #52's care plan to indicate the use of a foley catheter had been discontinued. The facility failed to update Resident #220's care plan to indicate the resident's diet, ADLs, and the use of an antipsychotic medication. as noted on the MDS The facility failed to revise Resident #15's care plan to indicate the presence of a newly acquired pressure wound. These failures could affect residents by not addressing their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, and psychosocial outcome.

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 observed for kitchen sanitation. Based 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 reviewed for food and nutrition services. Several food items in the refrigerator had use by dates that were expired but were still observed in refrigerator during initial kitchen observation. This failure could have the potential to affect residents who ate food from the facility's kitchen placing them at risk of foodborne illness. The facility failed to ensure hairnets and beard guards were worn while in the kitchen. [...]

Inspectors wroteBased on interviews and records reviews, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care for 1 (Resident #60) of 18 residents reviewed for base-line care plans. The facility failed to ensure (Resident #60) had a baseline care plan developed within 48-hours after admission with goals and interventions. The failure could place newly admitted residents at risks of not receiving the care and continuity of services.

Inspectors wroteBased on observation, interview 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 1 (Resident #170) of 1 resident reviewed for pharmacy services. LVN B failed to dissolve Resident #170's Dexamethasone 4 mg tablet, Famotidine 20 mg tablet, and Midodrine 15mg tablet in water prior to administering it through the g-tube. This failure could place residents with G-tubes (Gastrostomy tube) at risk of tube clogging/obstruction, tube replacement, medical complications, or a decline in health due to inappropriate G-tube care, management, and not following appropriate procedures. Findings Include: [...]

Inspectors wroteBased on observations, 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 of 3 residents (Resident #60) observed for infection control. LVN A failed to perform any hand hygiene (hand washing or hand sanitizing) with glove changes during wound care for Resident #60. This failure could place residents at risk of exposure to communicable diseases and infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to offer, based on resident's comprehensive assessment, a therapeutic diet when there was a nutritional problem, and the health care provider ordered a therapeutic diet for 2 of 5 residents (Residents #1 and #2) reviewed for therapeutic diets. The facility to ensure Resident #1 and Resident #2 received fortified meal plan as ordered by their physician. This failure could place residents who are on a modified diet at risk of weight loss and decline in health status. Findings Included: Resident #1 Record review of Resident #1's face sheet dated on 03/08/2024 revealed he was an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. [...]

Inspectors wroteBased on interviews and record review, the facility failed to immediately consult with the resident's physician of a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 (Resident #1) of 5 residents reviewed for resident rights. -The facility failed to immediately notify Resident #1's physician when Resident #1 had an unwitnessed fall related to a syncopal episode due to pulse in the 40's . This failure placed residents at risk of not receiving appropriate care and/or interventions.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident had a right to personal privacy and confidentiality of information during patient care for 1 resident (Resident #54) out of 8 residents reviewed for privacy and confidentiality. Nurse A failed to provide full visual privacy during incontinent and wound care for Resident #54. This failure could place residents at risk for low self-esteem, loss of dignity and decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a comprehensive resident centered care plan that included measurable objectives and timeframes to meet resident's needs for 1 of 16 residents reviewed for care plan accuracy (Resident #43). --Resident # 43 did not have an individualized care plan for ADL's. This failure placed residents at risk of not receiving care according to their needs and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents were free from any significant medication errors for 1 of 25 (Resident #21) residents reviewed for significant medication errors. The facility failed to hold Resident #21's Lisinopril medication, which lowers BP, when the resident had a BP below the safe parameters for administration. This failure could place residents with BP parameters at risk for symptoms of hypotension (low blood pressure), which could include dizziness, light headedness, lethargy (abnormal drowsiness), and unresponsiveness.