Paonia Care and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Paonia Care and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, patternF805Mar 1, 2024

  Based on record review, and observations, the facility failed to ensure seven (#6, #15, #14, #18, #33, #8, and #26) of nine residents with a dysphasia diagnosis out of 35 sample residents received food and fluids prepared in a form designed to meet their needs per physician orders and the residents' care plans. Observations of the tray line and dining room service on 2/28 and 2/29/24 revealed the facility failed to follow the residents' therapeutic diet orders. Seven out of seven residents, all with a dysphagia diagnosis, failed to receive a mechanically altered diet that required a change in texture (mechanical soft) as ordered and care planned. One of the seven residents failed to receive thickened liquid. […]

• Immediate jeopardy, patternF600Jun 15, 2022

  Based on record review and interviews, the facility failed to create an environment that protected 10 (#2, #4, #5, #8, #9, #10, #11, #12, #13 and #19) of 10 out of 23 sample residents from mental, physical and potential sexual abuse, contributing to residents experiencing repeated incidents of resident to resident abuse, three with injury (#2, #10 and #12), and two residents fearful of violence (#9 and #19). Other facility residents experienced repeated incidents of verbal abuse by Resident #8. Abusive incidents in April 2022 were followed by additional abusive incidents in May 2022, subjecting residents to physical abuse, mental abuse, verbal abuse and potential sexual abuse; and in June 2022, subjecting residents to physical abuse. […]

• Immediate jeopardy, patternF600Jul 29, 2021

  Based on observations, record review and interviews, the facility failed to provide a safe environment and protect residents from resident-to-resident abuse, involving six residents of seven reviewed (#16, #23, #29, #34, #44 and #199) out of 34 sample residents. Record review revealed a pattern of potentially sexually abusive behavior by Resident #199 towards Resident #44 on 6/29/21 and toward Resident #23 on 7/1/21. On 6/29/21, Resident #199 was found in Resident #44's bed and straddling her. The interaction alerted Resident #44's roommate and she called out for help. The roommate reported Resident #44 was scared to death and for a while, wanted someone to hold her hand until she fell to sleep. Two days later, Resident #199 climbed into Resident #23's bed and attempted to cuddle with her. […]

• Actual harm, patternF744Jun 15, 2022

  Based on record review and interviews, the facility failed to ensure six (#2, #5, #10, #11, #12 and #13) of 20 residents reviewed for dementia care out of 23 sample residents, received the appropriate treatment and services in dementia care to maintain their highest practicable physical, mental and psychosocial well-being and their freedom from repeated resident to resident abuse that included pushing, kicking and hitting and contributed to abrasions, skin tears, swelling and pain. Findings include: I. Professional standard The Gerontologist (February 2018), retrieved from: https://academic.oup.com/gerontologist/article/58/suppl_1/S1/ 59?login=true The Alzheimer's Association Dementia Care Practice Recommendations included the following foundations for person-centered care: 1. […]

• Actual harm, isolatedF760Jul 14, 2026

  Based on record review and interviews, the facility failed to ensure that residents were free from significant medication errors for one (#4) of three residents reviewed for medication errors out of 11 sample residents.Resident #4, who had a diagnosis of seizures, was admitted to the facility from home on 4/27/26 for a five-day respite stay. The resident had physician's orders for levetiracetam (a medication used to treat seizures) to be administered two times per day related to her seizures.The resident was scheduled to receive the levetiracetam medication between 3:00 p.m. and 6:00 p.m., per her home medication regimen. However, the medication orders were not obtained until 4:00 p.m. (over five hours after the resident was admitted to the facility). […]