Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Paramount Convalescent Hosp. during CMS and state inspections, most recent first.
A resident with a history of stroke, hemiplegia, and hypertension experienced multiple episodes of elevated blood pressure over several months without timely assessment or physician notification by nursing staff, despite care plan and physician orders requiring such actions. The resident was eventually transferred to the hospital with hypertensive urgency after further increases in blood pressure and the onset of a headache. Staff interviews confirmed that required monitoring and notification procedures were not followed.
A resident with an indwelling urinary catheter was observed without a privacy bag covering the drainage bag, compromising their dignity and privacy. Despite facility policies requiring privacy bags, staff failed to apply one, leading to potential embarrassment for the resident. Staff interviews confirmed awareness of the requirement to maintain resident dignity by covering drainage bags.
The facility failed to provide adequate care for residents with limited ROM and mobility, specifically for three residents. For one resident, baseline ROM measurements were not obtained, and the resident's orthosis was not assessed for fit and wear tolerance, leading to ROM limitations and a contracture. Another resident did not receive baseline ROM measurements, and ROM changes were not monitored over ten months, placing the resident at risk for further limitations. Additionally, a resident's hips were not positioned at midline while lying in bed, potentially contributing to further ROM limitations.
The facility failed to follow infection control protocols, including not changing tube feeding bags every 24 hours, improper hand hygiene during wound care, and inadequate handling of soiled linens. Additionally, shared care equipment was not disinfected between uses, and the facility lacked a Legionella water management program.
The facility failed to maintain proper nail hygiene for two residents, leading to deficiencies in personal care. One resident with arthritis had unclean and long nails, despite care plans requiring regular maintenance. Another resident with dementia and diabetes was observed with dirty nails while eating, with no documentation of care refusal. Staff interviews revealed a lack of communication and adherence to nail care policies.
Two residents in an LTC facility experienced inadequate pressure ulcer care. One resident developed a Stage 1 pressure injury on the nose due to improper monitoring of a nasal cannula, while another with a Stage 4 ulcer was not repositioned effectively, leading to potential worsening of the condition. Staff interviews revealed communication lapses and failure to adhere to skin assessment protocols.
The facility failed to provide effective pain management for two residents. One resident with hypertension and headaches was not assessed or treated for pain in a timely manner, and another resident with cognitive impairments was not assessed for pain appropriately. The facility's policy on pain management, requiring the use of appropriate assessment tools based on cognitive status, was not followed, leading to deficiencies in care.
The facility failed to conduct annual competency evaluations for RNAs, affecting 13 residents receiving RNA services. In one case, a resident with limited ROM and mobility did not receive proper PROM exercises, and assistance was needed to apply an orthosis. Additionally, a RNS and LVN were not competent in taking a resident's blood pressure before administering Nitroglycerin, using an incorrect cuff size, which could lead to inaccurate readings and adverse reactions.
A LTC facility failed to maintain a medication error rate below five percent, with errors observed in two residents due to late administration of medications. A resident with complex medical conditions received multiple medications significantly later than prescribed, while another resident also experienced delays. The LVN responsible did not inform physicians of the delays, potentially affecting medication effectiveness. The DON confirmed the need for timely administration and physician notification.
The facility failed to maintain sanitary conditions in the kitchen, with unlabeled food items and improper hand hygiene observed. A cook did not wash hands or change gloves between tasks and failed to wear a beard net, risking cross-contamination. These actions violated the facility's policies on food safety and hygiene.
A resident with hemiplegia and hemiparesis did not receive prescribed PT, SLP, and OT services despite having physician-signed care plans. The resident required assistance for ADLs and had impairments in mobility and communication. Evaluations recommended specific therapies, but these were not implemented due to a verbal agreement among therapists to use restorative nursing aide services instead, contrary to the physician's certification.
The facility failed to ensure accurate documentation for two residents with mobility concerns, leading to false records of care provided. Additionally, a medication administration record inaccurately reflected medication given to a resident, as an LVN documented under another's name, violating facility policy.
A resident with cognitive impairments and multiple diagnoses was found with bilateral 1/2 siderails on their bed without a physician's order, contrary to the facility's restraint-free policy. Staff confirmed the siderails were used as restraints, posing risks of entrapment and injury, and no proper assessment or monitoring was conducted.
An LVN failed to maintain a resident's head of the bed at the required 30-degree angle during g-tube medication administration, contrary to facility policy. The resident, with a history of dementia and other health issues, was positioned incorrectly, risking aspiration. Interviews confirmed the policy and the LVN's acknowledgment of the error.
Two residents in an LTC facility experienced deficiencies in pain management due to the facility's failure to implement comprehensive care plans. One resident's pain monitoring was delayed despite a care plan, while another resident with a Stage 4 pressure ulcer had no pain management plan, leading to observable distress. Staff interviews confirmed these oversights, highlighting a failure to adhere to facility policies on care planning and pain management.
A resident with limited mobility and cognitive impairment was transferred using a mechanical lift by a single CNA, contrary to the care plan and facility policy requiring two staff members. This action increased the risk of accidents, as observed by the DON, who intervened to stop the transfer.
A resident with multiple mental health diagnoses was prescribed Alprazolam for anxiety without documented non-pharmacological interventions being attempted first. Facility staff, including an LVN and the RN Supervisor, confirmed that interventions like providing a calm environment or assessing for pain were not used before administering the medication. The facility's policy required such interventions to be attempted to avoid unnecessary psychotropic medication use.
A resident with end-stage renal disease and diabetes did not receive meals that accommodated her food preferences, despite dietary interventions in her care plan. The resident reported receiving unsuitable foods, and staff confirmed that her dislikes were communicated but not addressed. The facility's policy to obtain and note food preferences was not followed, risking decreased meal intake and weight loss.
A resident with legal blindness and intact cognitive function signed an arbitration agreement without proper explanation or assistance. Interviews revealed that the facility did not follow protocol, as the resident was not fully informed of the agreement's implications, and no witness was present during the signing.
The QAA Committee failed to implement corrective actions for RNA services, leading to repeated deficiencies in providing ROM and mobility services. A resident with hemiplegia received fewer AROM exercises than required, another did not consistently receive a palm guard or daily exercises, and a third resident with end-stage renal disease received PROM less frequently than needed. The DON confirmed the lack of evidence that these issues were addressed in QAA meetings.
A facility failed to maintain the wall in a resident's room, where a hole was observed in the drywall behind the bed. The Maintenance Supervisor confirmed the hole was not reported in the Maintenance Log, despite daily room rounds. The resident, with multiple health conditions, required assistance for daily activities. The facility's Preventative Maintenance Program policy was not followed, leading to the deficiency.
Failure to Assess and Notify Physician for Elevated Blood Pressure
Penalty
Summary
The facility failed to assess a resident during multiple episodes of elevated blood pressure and did not notify the physician in a timely manner, as required by the resident's care plan and physician orders. The resident, who had a history of hemiplegia, cerebral infarction, atherosclerotic heart disease, and hypertension, was cognitively impaired and required varying levels of assistance with daily activities. Physician orders and care plans directed staff to monitor blood pressure regularly and notify the physician of significant abnormalities or changes in condition. Despite these directives, the resident experienced several documented episodes of systolic blood pressure above 150 mmHg over a period of months, with no evidence that staff assessed the change in condition or notified the physician as required. On the day of transfer to an acute care hospital, the resident had multiple high blood pressure readings and reported a headache, but staff did not notify the physician until after the condition had escalated. Upon arrival at the hospital, the resident was diagnosed with hypertensive urgency. Interviews with nursing staff and the DON confirmed that staff did not follow the care plan or facility policy regarding monitoring and physician notification for elevated blood pressure. Facility policies and job descriptions required staff to observe for changes in resident status, notify the physician and family, and document accordingly, but these procedures were not followed in this case.
Failure to Maintain Resident Dignity by Not Covering Catheter Bag
Penalty
Summary
The facility failed to ensure that a resident's indwelling urinary catheter drainage bag was covered with a privacy bag, compromising the resident's dignity and privacy. The resident, who was admitted with diagnoses including type 2 diabetes mellitus and urinary retention, had moderate cognitive impairment and required substantial assistance for toileting and showering. During an observation, it was noted that the resident's catheter drainage bag was not covered, which was confirmed by multiple staff members, including a CNA, LVN, and RNS, who acknowledged the importance of maintaining resident dignity by covering drainage bags. The facility's policy and procedure on catheter care, dated December 19, 2022, indicated that privacy bags should be available and used to cover catheter drainage bags at all times. Despite this policy, the staff failed to apply a privacy bag to the resident's drainage bag, leading to the potential for the resident to feel embarrassed and have low self-esteem. Interviews with the staff revealed that they were aware of the requirement to cover drainage bags to maintain resident dignity, yet the deficiency occurred, indicating a lapse in adherence to the facility's established procedures.
Failure to Provide Adequate ROM Care for Residents
Penalty
Summary
The facility failed to provide adequate care for residents with limited range of motion (ROM) and mobility, specifically for three residents. For Resident 43, the facility did not obtain baseline ROM measurements upon admission and during occupational therapy evaluation. The resident's left wrist hand orthosis was not assessed for fit and wear tolerance upon discharge from occupational therapy services. Additionally, the facility did not provide restorative nursing assistant services for passive range of motion exercises and the application of the orthosis for extended periods, leading to the development of ROM limitations and a contracture in the left hand. Resident 5 also did not receive baseline ROM measurements upon admission and during physical and occupational therapy evaluations. The facility failed to monitor ROM changes over a ten-month period, placing the resident at risk for further ROM limitations. The resident's care plan included interventions for passive range of motion exercises and the application of a palm guard, but these were not consistently implemented, as observed during interviews and record reviews. For Resident 18, the facility did not position the resident's hips at midline while lying in bed, which could contribute to further ROM limitations. The facility's failure to adhere to its policies and procedures for joint mobility screening and assessment, as well as the lack of consistent monitoring and implementation of recommended interventions, resulted in deficiencies in the care provided to these residents.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to infection control measures, resulting in several deficiencies. For instance, the facility did not ensure that tube feeding and water bags for two residents were changed every 24 hours, as confirmed by multiple staff members, including a Licensed Vocational Nurse, a Registered Nurse Supervisor, and the Director of Nursing. This oversight was acknowledged by the staff, who stated that the bags should be changed daily to prevent infection. In another instance, a Treatment Nurse failed to perform hand hygiene during wound care treatment for a resident with a Stage 4 pressure injury. The nurse changed gloves without washing hands between handling soiled dressings and applying medication, which was against the facility's policy. This was confirmed by the Infection Prevention Nurse and the Director of Nursing, who emphasized the importance of hand hygiene to prevent cross-contamination. Additionally, the facility did not handle dirty linens properly after providing personal care to a resident with ESBL, a resistant bacterial infection. A Certified Nursing Assistant was observed carrying soiled linens without placing them in a plastic bag, contrary to the facility's policy. The Infection Prevention Nurse confirmed that this practice could lead to cross-contamination. Furthermore, the facility lacked a Legionella water management program, which was acknowledged by the Maintenance Supervisor and the Administrator, indicating a potential risk for Legionella growth.
Deficiency in Nail Care for Residents
Penalty
Summary
The facility failed to ensure proper nail care for two residents, leading to deficiencies in personal hygiene and potential health risks. Resident 17, who suffers from Psoriatic Arthritis Mutilans and atrial fibrillation, was observed with unclean and long fingernails. Despite being unable to cut his own nails due to arthritis, the care plan for Resident 17 included interventions to maintain clean and short nails to prevent skin injuries and infection. However, observations and interviews revealed that the resident's nails were not properly maintained, and there was a lack of documentation indicating the need for nail trimming. Similarly, Resident 45, diagnosed with diabetes mellitus, unspecified dementia, and osteoporosis, was observed with long and dirty fingernails. The care plan for Resident 45 included regular nail care as part of daily living activities, but observations showed the resident eating with unclean nails, posing a risk of ingesting bacteria. Interviews with staff indicated a lack of communication and documentation regarding the resident's refusal of nail care, and there was no care plan addressing noncompliance or refusal of care. The facility's policy and procedure on nail care emphasized routine cleaning and inspection during daily living activities, yet these were not adequately followed for the two residents. The failure to maintain proper nail hygiene for Residents 17 and 45 was confirmed through observations, interviews, and record reviews, highlighting a deficiency in the facility's care practices.
Inadequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for two residents, leading to deficiencies in their treatment. Resident 39, who was admitted with conditions including aphasia, Alzheimer's disease, and a respiratory disorder, developed a Stage 1 pressure injury on the nose due to improper monitoring of the nasal cannula. Despite being dependent on staff for personal care and having a high risk for pressure injuries as indicated by a Braden Scale score of 11, the redness on the nasal septum was not reported or addressed in a timely manner. The CNA noticed the redness and applied ointment but did not effectively communicate this to the LVN, who failed to conduct the necessary skin checks. Resident 18, who had a Stage 4 pressure ulcer on the sacrococcyx area and contractures in both knees, was not repositioned adequately to offload pressure from the affected area. Despite having a care plan that included interventions to prevent further skin breakdown, the resident was often found lying on his back, which could exacerbate the pressure injury. The staff struggled to reposition the resident due to his contractures and frequent movements, and the use of pillows for repositioning was ineffective as the resident often removed them. Interviews with staff revealed a lack of communication and adherence to protocols for monitoring and reporting skin conditions. The facility's policy required regular skin assessments and immediate reporting of any concerns, but these were not consistently followed. The DON acknowledged that improper repositioning and ineffective interventions could lead to worsening pressure injuries, highlighting the need for better monitoring and assessment practices.
Inadequate Pain Management for Residents with Cognitive Impairments
Penalty
Summary
The facility failed to provide effective pain management for two residents, leading to deficiencies in care. Resident 11, who was admitted with hypertension and headaches, was not assessed or treated for pain in a timely manner. Despite having a care plan that required pain monitoring every four hours, this was not initiated until a day after the plan was updated. On one occasion, Resident 11 reported having a headache since the morning and had not received his scheduled medication. The LVN responsible for administering the medication admitted to not doing so because Resident 11 was sometimes difficult, and he forgot to ask another nurse to assist. This oversight was acknowledged by the RN Supervisor and the DON, who emphasized the importance of pain assessment, especially given Resident 11's hypertension, which could lead to serious complications like a stroke. Resident 18, who had multiple diagnoses including a stage 4 pressure ulcer and cognitive impairments, was also not assessed for pain appropriately. The resident's cognitive impairments made it difficult for them to communicate pain levels effectively using a numerical pain rating scale. Despite this, the LVN used this method to assess pain, which was not suitable given the resident's condition. During a wound dressing change, Resident 18 exhibited nonverbal signs of pain such as moaning and grimacing, which were not adequately considered in the pain assessment. Both the RN Supervisor and the DON acknowledged that nonverbal signs should have been used to assess pain due to the resident's cognitive limitations. The facility's policy on pain management, which requires the use of appropriate pain assessment tools based on a resident's cognitive status, was not followed. This resulted in inadequate pain management for Resident 18, as the staff did not use nonverbal indicators to assess pain. The failure to adhere to the policy and properly assess pain in residents with cognitive impairments led to deficiencies in the care provided to both Resident 11 and Resident 18.
Deficiencies in Staff Competency Evaluations and Blood Pressure Monitoring
Penalty
Summary
The facility failed to ensure that five Restorative Nursing Assistants (RNAs) had their annual competency evaluations for providing range of motion (ROM) exercises, application of orthotics, and ambulation to 13 residents receiving RNA services. This deficiency was observed during an interview with the Director of Rehabilitation, who confirmed that the purpose of the RNA program was to maintain residents' function and prevent decline in mobility. The competency evaluations for the RNAs were last completed in May 2023, and should have been completed again in May 2024, but were not. This lapse in competency evaluations had the potential to affect the quality of care provided to residents, including Resident 43, who had limited ROM and mobility due to conditions such as end-stage renal disease and hemiplegia. In a specific incident, Resident 43 was observed receiving RNA services, where RNA 1 and RNA 2 performed exercises on the resident's limbs. However, RNA 2 was unable to fully extend the resident's left-hand fingers and required assistance to apply a left wrist-hand orthosis. RNA 2 also forgot to perform PROM exercises on the resident's left elbow. This incident highlighted the lack of competency in performing necessary tasks, which could lead to a decline in the resident's ROM and mobility. Additionally, the facility failed to ensure that a Registered Nurse Supervisor (RNS) and a Licensed Vocational Nurse (LVN) were competent in taking a resident's blood pressure before administering Nitroglycerin. Resident 27, who had conditions such as morbid obesity and congestive heart failure, complained of chest pain, and the RNS used an incorrect blood pressure cuff on the forearm instead of the upper arm. This could have resulted in an inaccurate blood pressure reading, potentially leading to adverse reactions with the medication. The facility's policy indicated that staff should have the appropriate competencies to ensure resident safety, which was not adhered to in this case.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by eleven medication errors out of thirty-three opportunities, resulting in a 33.33 percent error rate. This deficiency was observed in two of the four sampled residents, specifically Residents 28 and 37. The errors were primarily due to the late administration of medications, which were not given within the facility's protocol time frame of one hour before or after the scheduled time. Resident 28, who has a complex medical history including acute and chronic respiratory failure, pulmonary hypertension, hypertensive heart disease, epilepsy, diabetes mellitus type 2, diabetic neuropathy, and dementia, received multiple medications significantly later than the prescribed time. Medications such as Amiodarone, Apixaban, Budesonide, Levetiracetam, Pregabalin, and Sildenafil were administered well past the scheduled 9:00 a.m. time, with some given as late as 2:16 p.m. Similarly, Resident 37, with diagnoses including hypertensive heart disease, cerebral infarction, and depression, also received medications like Finasteride, Gabapentin, and Hydralazine later than scheduled. The Licensed Vocational Nurse (LVN) responsible for administering these medications acknowledged the delay and stated that the facility protocol allows for a two-hour window for medication administration. However, the LVN did not inform the residents' physicians of the delays, which could potentially affect the therapeutic effectiveness of the medications. The Director of Nursing confirmed that the medications should have been administered within the specified time frame and that the physicians should have been notified of any delays to ensure proper treatment outcomes.
Sanitation and Hygiene Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed during a survey. Several food items, including an open bag of peanut butter dough, frozen fries, and bottles of salsa, were found without proper labeling and dating, which is essential to prevent foodborne illnesses. Interviews with kitchen staff confirmed that these items should have been labeled with the date they were opened and a use-by date, as per the facility's policy. This oversight was acknowledged by the staff, who recognized the importance of labeling to ensure food safety. Additionally, a cook was observed not practicing proper hand hygiene during food preparation and distribution. The cook did not wash hands or change gloves between tasks, such as cooking, checking food temperatures, and plating meals, which is a critical step in preventing cross-contamination. Furthermore, the cook did not wear a beard net while handling food, despite having facial hair, which could lead to contamination. These practices were contrary to the facility's policies on handwashing, glove use, and personal hygiene, which are designed to maintain a safe and sanitary environment.
Failure to Provide Required Therapy Services
Penalty
Summary
The facility failed to provide necessary therapy services to a resident with significant mobility and communication concerns, as outlined in the resident's physician-signed care plans. The resident, who had been diagnosed with hemiplegia and hemiparesis following a cerebral infarction, was admitted with functional range of motion limitations and required various levels of assistance for activities of daily living. Despite having care plans for physical therapy (PT), speech therapy (SLP), and occupational therapy (OT) that were signed and certified by the resident's physician, these services were not implemented. The PT evaluation indicated that the resident had impaired range of motion in both ankles and required therapeutic exercises, neuromuscular reeducation, and other interventions three times per week for four weeks. Similarly, the SLP evaluation identified mild to moderate oral dysphagia, necessitating treatment twice a week for four weeks. The OT evaluation noted impairments in the right shoulder, wrist, and hand, with a contracture in the right hand, and recommended therapy three times per week for one week. Despite these evaluations and plans, the therapies were not provided, and the resident did not receive any interventions to improve communication, mobility, or activities of daily living. Interviews with the Director of Rehabilitation and the Director of Nursing revealed that the resident's therapy plans were not implemented because the resident was considered totally dependent for mobility and ADLs. Instead, there was a verbal agreement among the therapists that the resident would benefit more from restorative nursing aide services rather than therapy. This decision was made despite the physician's certification of the need for therapy services, and the facility's policy aimed at restoring residents to their highest level of function.
Inaccurate Documentation and Medication Administration Errors
Penalty
Summary
The facility failed to ensure accurate documentation for two residents with limited range of motion and mobility concerns. For one resident, the documentation inaccurately recorded that a Restorative Nursing Assistant (RNA) provided passive range of motion (PROM) exercises and applied a wrist-hand orthosis (WHO) on a day when the RNA was on vacation and not present at the facility. Observations and interviews revealed that the resident did not receive the prescribed exercises and orthosis application as documented, indicating false and inaccurate record-keeping. Another resident's documentation inaccurately reflected that an RNA provided active range of motion (AROM) exercises to both legs on specific dates. However, interviews revealed that the RNA did not perform these exercises due to a past conflict with the resident, and the documentation was completed by the RNA without providing the services. This led to inaccuracies in the resident's clinical records, as the actual services provided were not documented by the RNAs who performed them. Additionally, the facility failed to ensure that a medication administration record (MAR) accurately reflected the administration of medication to a resident. A Licensed Vocational Nurse (LVN) documented under another LVN's name, leading to potential liability issues and inaccuracies in the resident's medical records. The facility's policy requires that the individual who administers medication records the administration directly after the medication is given, which was not followed in this instance.
Improper Use of Physical Restraints on a Resident
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, as evidenced by the use of bilateral 1/2 siderails on the resident's bed without a physician's order or assessment. The resident, who was admitted with diagnoses including major depressive disorder, bipolar disorder, schizoaffective disorder, and contracture of both knees, was observed with siderails that were not ordered by a physician. The resident's cognitive skills were moderately impaired, requiring substantial assistance with daily activities, and the use of these siderails was not in compliance with the physician's order for 1/4 assist devices. Observations revealed that the resident was lying in bed with both 1/2 siderails up, which was confirmed by the RN Supervisor as being against the physician's order. Interviews with staff, including a CNA, LVN, and the DON, indicated that the use of these siderails was considered a form of restraint, as they restricted the resident's movement and could lead to potential risks such as skin tears, fractures, or entrapment. The facility's policy on a restraint-free environment was not adhered to, as there was no monitoring or assessment for the use of these siderails. The facility's policy and procedure emphasized the prohibition of restraints for discipline or convenience, and required behavioral interventions to be exhausted before applying physical restraints. However, the use of bilateral 1/2 siderails without proper authorization and assessment demonstrated a failure to comply with these guidelines, placing the resident at risk for unnecessary restraint and associated complications.
Improper Positioning During G-Tube Medication Administration
Penalty
Summary
Licensed Vocational Nurse (LVN) 4 failed to maintain the head of the bed for Resident 38 at a minimum of 30 degrees during the administration of medications through a gastrostomy tube (g-tube), as per the facility's policy and procedure. This failure was observed during an incident where LVN 4 checked the g-tube for placement and residual while Resident 38 was lying on her right side at a 20-degree angle. LVN 4 then began administering medications without re-checking the g-tube placement or residual after repositioning Resident 38 to a 75-degree angle on her back. Resident 38 had a medical history that included a gastrostomy tube for feeding, hypertensive heart disease, depression, diabetes mellitus type 2, and dementia. The resident was noted to have impaired cognitive skills and was unable to make decisions for herself. The facility's policy required the head of the bed to be elevated at a minimum of 30 degrees during feeding or medication administration to prevent aspiration and pneumonia. Interviews with LVN 4, the Director of Staff Development (DSD), and the Director of Nursing (DON) confirmed the facility's policy and the importance of proper positioning to prevent aspiration pneumonia. LVN 4 admitted to positioning Resident 38 incorrectly to save time, acknowledging the risk of aspiration and potential fatality. The facility's policy and procedure documents reiterated the need for proper positioning during enteral feeding and medication administration.
Deficiencies in Pain Management for Two Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-focused care plan for two residents, leading to deficiencies in pain management. Resident 11 was admitted with diagnoses including hypertension and headaches. A care plan was initiated on October 2, 2024, focusing on managing Resident 11's constant pain with an intervention to monitor pain every four hours. However, documentation showed that pain monitoring did not begin until October 3, 2024, at 4:00 p.m., indicating a delay in implementing the care plan. Interviews with staff confirmed that the care plan was not followed as required, placing Resident 11 at risk for delayed care and treatment. Resident 18, who was readmitted with multiple diagnoses including a Stage 4 pressure ulcer, major depressive disorder, and cognitive impairments, did not have a care plan addressing pain despite observable signs of distress during wound dressing changes. The resident was observed moaning and grimacing, yet no care plan was in place to manage the pain associated with the pressure ulcer. Interviews with nursing staff revealed that a care plan for pain was only initiated after the surveyor began investigating the issue, highlighting a significant oversight in addressing the resident's pain management needs. The facility's policies and procedures require the development of a comprehensive care plan within seven days of completing the Minimum Data Set assessment, including measurable objectives and timeframes to meet residents' needs. Additionally, the facility's pain management policy emphasizes the importance of managing pain in accordance with the comprehensive assessment and plan of care. The failure to adhere to these policies resulted in inadequate pain management for both residents, as evidenced by the lack of timely interventions and documentation.
Inadequate Supervision During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure adequate supervision and adherence to safety protocols during the transfer of a resident with limited range of motion and mobility. Resident 18, who has diagnoses including parkinsonism, autistic disorder, and contractures of both knees, was observed being transferred by a single Certified Nursing Assistant (CNA) using a mechanical lift, despite the care plan and facility policy requiring two staff members for such transfers. This action was observed during a transfer from the bed to the shower bed, placing the resident at increased risk for accidents, including potential falls and physical injury. The deficiency was identified during an observation where CNA 10 was seen operating the mechanical lift alone, contrary to the facility's policy and the resident's care plan, which both mandate two-person assistance for mechanical lift transfers. The Director of Nursing (DON) intervened during the observation, instructing CNA 10 to halt the transfer and wait for additional assistance. CNA 10 later acknowledged the requirement for two-person assistance but cited the unavailability of other staff as the reason for proceeding alone. The facility's policy on Safe Resident Handling/Transfers, revised earlier in the year, clearly states the necessity of two staff members for mechanical lift transfers to ensure resident safety and minimize injury risk.
Failure to Implement Non-Pharmacological Interventions Before Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 18, was free from unnecessary medication by not implementing non-pharmacological interventions before administering psychotropic medication. Resident 18, who was diagnosed with major depressive disorder, bipolar disorder, schizoaffective disorder, and autistic disorder, was prescribed Alprazolam for anxiety manifested by an inability to relax. However, there was no documentation of non-pharmacological interventions being attempted prior to the administration of Alprazolam, which could lead to unnecessary use of psychotropic medication. Interviews with facility staff, including an LVN and the RN Supervisor, revealed that non-pharmacological interventions such as offering food, repositioning, providing a calm environment, listening to music, and assessing for pain were not utilized before administering Alprazolam. The RN Supervisor and the Director of Nursing acknowledged that the behavior described as 'inability to relax' was too general and not specific enough to warrant the use of Alprazolam. The facility's policy required that non-pharmacological interventions be attempted to facilitate the reduction or discontinuation of psychotropic drugs, and that PRN orders for such medications should only be used when necessary for a diagnosed specific condition with documented rationale.
Failure to Accommodate Resident's Food Preferences
Penalty
Summary
The facility failed to provide meals that accommodated the food preferences of a resident with end-stage renal disease, diabetes mellitus, and dependence on renal dialysis. The resident, who had fluctuating capacity to understand and make decisions, was dependent on staff for various activities of daily living. The care plan for the resident included dietary interventions to regulate protein and potassium intake and to follow up with the resident's food preferences. However, the meal tray card for the resident did not indicate any food preferences or dislikes, and the resident reported receiving foods like potatoes, yams, and cheese, which were not suitable for her kidney condition. Interviews with staff revealed that the resident's dislike for certain foods, such as cheese on scrambled eggs, was communicated to the dietary manager, but no action was taken to address these preferences. The dietary manager confirmed that nutritional assessments are conducted upon admission and as needed, but was unaware of the resident's dislike for cheese. The facility's policy required obtaining food preferences and noting them in the dietary records, but this was not followed, leading to the potential for decreased meal intake and weight loss for the resident.
Failure to Ensure Resident Understanding of Arbitration Agreement
Penalty
Summary
The facility failed to ensure that a resident was fully informed and aware of the implications of signing a binding arbitration agreement. The resident, who was legally blind and had a diagnosis of Diabetes Mellitus, was admitted to the facility and signed the arbitration agreement. However, during an interview, the resident stated that she could not recall signing the agreement or having it explained to her. She also mentioned that she would not have signed such an agreement if she had understood its nature. The resident's cognitive function was assessed as intact, but her visual impairment required assistance for signing documents, which was not adequately provided. Interviews with the Admissions Coordinator and the Director of Nursing revealed that the proper protocol was not followed when the resident signed the arbitration agreement. The Admissions Coordinator, who was not employed at the facility at the time, stated that a witness should have been present due to the resident's blindness. The Director of Nursing confirmed that the resident should not have been asked to sign the agreement without a family member or representative present, as it compromised her rights. The facility's policy required that residents or their representatives acknowledge understanding the agreement, which was not ensured in this case.
Failure to Implement Corrective Actions for RNA Services
Penalty
Summary
The Quality Assessment Assurance (QAA) Committee at the facility failed to implement corrective actions from a previous re-certification survey concerning the Restorative Nursing Aide (RNA) services. This failure resulted in repeated deficiencies related to the provision of range of motion (ROM) and mobility services. Specifically, the facility did not ensure that passive range of motion (PROM) exercises and splint applications were consistently provided to residents as per their care plans. For instance, Resident 32, who was admitted with hemiplegia and hemiparesis, was supposed to receive active range of motion (AROM) exercises five times a week but reported receiving them only twice a week. Similarly, Resident 5, with similar diagnoses, was not consistently provided with a palm guard or daily exercises as required by their care plan. Resident 43, who had end-stage renal disease and hemiplegia, was supposed to receive PROM and have a wrist hand orthosis applied five times a week but reported receiving exercises only once a week. The Director of Nursing (DON) confirmed the lack of evidence that these deficiencies were addressed in QAA meetings, indicating a systemic issue in addressing and correcting the RNA service deficiencies.
Facility Failed to Maintain Wall Integrity in Resident's Room
Penalty
Summary
The facility failed to maintain the wall in one of its rooms, specifically Room A, where a hole was observed in the drywall behind a resident's bed. This deficiency was identified during observations and interviews conducted over several days. The Maintenance Supervisor confirmed that the hole was not reported in the facility's Maintenance Log, despite daily room rounds being performed by the maintenance staff. The presence of the hole posed potential hazards, including the risk of water, fire, and pest intrusion into the resident's room. The resident involved, identified as Resident 27, was admitted with multiple health conditions, including morbid obesity, hypertensive heart disease, congestive heart failure, type 2 diabetes mellitus, and reduced mobility. The resident required varying levels of assistance for daily activities and was found lying awake in bed during the observation. The facility's Preventative Maintenance Program policy indicated that the Maintenance Director was responsible for ensuring the safety and operability of the building, but the hole in the drywall was not addressed, leading to the deficiency.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 5,102 citations issued within 25 miles in the last 12 months — including the 21 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Paramount
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| La Paz Geropsychiatric Center | 1 mi | — | 31 | 0 |
| Downey Post Acute | 1.2 mi | — | 3 | 0 |
| Meadow Creek Post-acute | 2 mi | — | 15 | 0 |
| Lakewood Healthcare Center | 2 mi | — | 42 | 0 |
| Sunset Villa Post Acute | 2.1 mi | — | 23 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Paramount Convalescent Hosp..
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.