Paddock Springs

In the surveyor’s words

From the most serious findings on record at Paddock Springs, in the surveyor’s own words.

• Actual harm, isolatedF760Oct 16, 2024

  Based on interview and record review, the facility failed to clarify conflicting hospital discharge orders and previous medication orders for appropriate dosing of a blood pressure medication. This deficient practice resulted in a significant medication error which required hospitalization for 1 of 3 residents reviewed for hospitalization . (Resident 9) Finding includes: A record review was completed for Resident 9 on 10/10/2024 at 8:29 A.M. Diagnoses included, but were not limited to: congestive heart failure, hypertensive heart disease with heart failure, and essential hypertension Resident 9's record indicated she returned to the facility on [DATE] at 1:30 P.M. after a hospitalization for sepsis, urinary tract infection and acute kidney injury. […]

• Actual harm, isolatedF689Jun 4, 2021

  Based on observations, interview and record review, the facility failed to follow a resident's fall care plan interventions and safety measures, in 1 of 3 residents reviewed for accidents/falls. This deficient practice resulted in a fall requiring hospitalization , for a traumatic dental injury, and oral surgery. (Resident E) The deficient practice was corrected on May 15, 2021, prior to the start of the survey, and was therefore Past Noncompliance. Finding includes: On 6/3/21 at 11:35 A.M., Incident #244 was received from the Administrator. […]

• No harm, potential for more than minimal, isolatedF684Mar 31, 2025

  Based on record review and interview, the facility failed to implement timely and effective interventions to prevent abrasions due to bed placement for 1 of 4 residents reviewed for skin alterations. (Resident B) Finding includes: A record review for Resident B was completed on 3/31/2025 at 9:58 A.M. Diagnoses included, but were not limited to: Alzheimer's disease, diabetes mellitus type 2, neuropathy, overactive bladder and peripheral angiopathy. A Quarterly MDS assessment, dated 1/8/2025, indicated Resident B had moderate cognitive impairment, required substantial/maximal assistance for bed mobility and had a pressure ulcer but no other treatments or open wounds. […]

• No harm, potential for more than minimal, isolatedF686Mar 31, 2025

  Based on record review and interview, the facility failed to identify a pressure ulcer until it was necrotic and deemed an unstageable ulcer, implement orders for treatment timely and obtain and implement timely nutritional interventions for 1 of 4 residents reviewed for pressure ulcers. (Resident B) Finding includes: A record review for Resident B was completed on 3/31/2025 at 9:58 A.M. Diagnoses included, but were not limited to: Alzheimer's disease, diabetes mellitus type 2, neuropathy, overactive bladder and peripheral angiopathy. A Quarterly Minimum Data Set (MDS) assessment, dated 10/8/2024, indicated Resident B had moderate cognitive impairment, required substantial/maximal assistance for bed mobility and was at risk for pressure ulcer development. […]

• No harm, potential for more than minimal, isolatedF580Oct 16, 2024

  Based on record review and interview, the facility failed to notify the physician of medications held for 1 of 1 resident reviewed for physician notification (Resident 4). Finding includes: The clinical record for Resident 4 was reviewed on 10/9/2024 at 1:27 P.M. Diagnoses included, but were not limited to: chronic obstructive pulmonary disease, chronic kidney disease, heart failure, schizoaffective disorder, psychotic disorder with known delusions, hypertension, bipolar disorder, depression, anxiety, diabetes mellitus, dementia and borderline personality disorder. A Quarterly Minimum Data Set (MDS) assessment, dated 7/18/2024, indicated the resident was taking an antidepressant medication, an antianxiety medication and a diuretic medication. […]