Paradigm at Stevens

In the surveyor’s words

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

• Immediate jeopardy, patternF689Jan 26, 2021

  Based on observation, interview, and record review revealed the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 of 8 residents (Residents #1 and #4) reviewed for supervision for elopement, in that: There was not adequate supervision for Residents #1 and #4 who had histories of elopement and were at risk for elopement and inadequate interventions were put in place after the Residents' first elopements while the facility's wander guard alarm system was not operational and the two dining room doors were not equipped with an alarm system that would alert staff if a resident exited either door. An Immediate Jeopardy (IJ) was identified on 1/22/21. […]

• Actual harm, isolatedF689Jul 19, 2022

  Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 resident reviewed (Resident #1) accidents in that: CNA A attempted to complete peri-care for Resident #1 alone when the resident's MDS called for two-person assist, resulting in the resident falling from the bed and sustaining a neck fracture. This failure could place residents who require two-person assistance for transferring, peri-care, and repositioning at risk of injury. […]

• No harm, potential for more than minimal, widespreadF812Mar 7, 2025

  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 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. […]

• No harm, potential for more than minimal, widespreadF812Sep 16, 2021

  Based on observation, interview and record review the facility failed to store foods in accordance with professional standards for food safety for 1 of 1 kitchen reviewed for kitchen sanitation in that: 1. The facility failed to make sure the walk-in refrigerator was maintaining a temperature at 41 degrees Fahrenheit or below for 13 days and continued to use food in the malfunctioning walk-in refrigerator during the time that it was not maintaining the appropriate temperature. 2. The facility failed to store foods at recommended temperatures in the walk-in refrigerator that were labeled by the suppliers store frozen or keep frozen. This failure resulted in an identification of an Immediate Jeopardy (IJ) situation on 09/13/2021. […]

• No harm, potential for more than minimal, widespreadF835Jan 26, 2021

  Based on observation, interview and record review the ED failed to administer the facility in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical and psychosocial well-being of each resident for 2 of 8 Residents (Resident #1 and Resident #4) whose records were reviewed for elopements. 1. The ED and the Maintenance Supervisor failed to: · ensure the wander guard alarm system by the front door was operating properly for about 2 months; · check the wander guard system on the back door, at the end of the front hall, and on the back door, at the end of the east hall for functionality for about 4 months and; · there was an exit alarm on the back door at the end of the east hall which would alert staff anytime the door… […]