Paradigm at the Creek

Inspectors wroteBased on observation, interview and record review the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 6 residents (CR #1) reviewed for comprehensive care plans. The facility failed to develop a care plan area for CR #1's hyperammonemia. The facility failed to implement CR #1's care plan interventions related to medication management and behaviors by not administering prescribed routine dosage of lactulose from 5/4/2026 - 5/23/2026 resulting in approximately 57 missed doses. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 6 residents (CR #1) reviewed for medication errors. The facility failed to provide CR #1 with lactulose 30mg three times a day to manage ammonia levels from 5/4/2026 - 5/23/2026 resulting in approximately 57 missed doses. This failure placed residents at risk for elevated ammonia levels which could seriously impair him or cause increased behaviors.

Inspectors wroteBased on interview and review the facility failed to report alleged violations of abuse, neglect, exploitation of mistreatment, including injuries of unknown source. Immediately but no later than two hours if the events that cause the allegation involve abuse or result in serios bodily injury for 1 out of 1 incident (Resident # 1) sampled for abuse and neglect. The facility failed to report an unwitnessed fall of Resident # 1 that resulted in a fracture of clavicle. This failure places residents at risk of not receiving complete or accurate investigation of incidents that resulted in emergency services implementing interventions.

Inspectors wroteBased on interview and record review the facility failed to conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity for 1 out of 4 (Resident #1) residents reviewed for resident assessmentsThe facility failed to revise Resident # 1 MDS to address cellulites (a common, potentially serious bacterial skin infection)of right lateral foot and right ankle and the intervention of antibiotics. This failure causes a risk to residents not receiving current or updated treatment and monitoring of infections based on MDS triggered Care Plans Area.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure each resident was free from abuse for 1 of 16 residents (Resident #1) reviewed for abuse. Resident #2 was physically abusive to Resident #1 on 3/5/26 when he punched her with a closed fist in the head after which Resident #1 was observed crying and upset. The noncompliance was identified as past noncompliance (PNC). The noncompliance began on 3/5/26 and ended on 3/6/26. The facility corrected the noncompliance before the survey began. These failures placed residents, who resided in the facility, at risk of abuse, pain and emotional distress.

Inspectors wroteBased on interviews and record reviews, the facility failed to have evidence that the alleged violation was thoroughly investigated in response to allegations of abuse or neglect for 7 of 16 residents reviewed for freedom from abuse and neglect (Residents #1, #4, #5, #6, #7, #9, and #11). The Administrator failed to have evidence that an alleged violation of an injury of unknown origin was thoroughly investigated and included witness statements from staff members when Resident #4 was found to have a fractured toe on 2/26/26. The Administrator failed to have evidence that an alleged violation of abuse was thoroughly investigated and included witness statements from staff members when Resident #1 was hit in the head by Resident #2 on 3/5/26. [...]

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 #2) reviewed for accident hazards. The facility failed to ensure Resident #2 had an adequate assistance device in that his wheelchair brake was inoperable, resulting in a fall on 3/10/26. Resident #2 had been using the wheelchair between 3/10/26 and 5/6/26. This failure could place residents at risk for falls, pain and injuries.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (CR#1) of 6 residents reviewed for comprehensive care in that:-The facility failed to ensure CR#1's care plan interventions had not been updated since 2024 despite recent falls including falls with injury. CR#1 had unwitnessed falls on 07/08/25 and another on 07/10/25. CR#1 was transported to the hospital where she was diagnosed with rib fractures and had a chest tube placed. An Immediate Jeopardy (IJ) situation was identified on 8/1/2025 at 3:30pm. [...]

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 in 1 of 1 kitchen reviewed for food procurement. 1. The facility failed when Dietary Aide A and Dietary Aide B did not don (put on) hair nets while preparing breakfast in the facility kitchen on 05/20/2025. These failures could place residents at risk of food borne illness and disease.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 1 of 3 showers (shower room on Hall A) reviewed for resident rights. 1. The facility failed to ensure the shower room floor did not have black marks with debris on floor. 2. The facility failed to ensure resident personal care items were labeled. 3. The facility failed to ensure 2 full sharp containers were not filled with razors, 2 wheelchair footrests were not on the floor, linen was not laying on the seat of a wheelchair, and a pair of rainboots were not under one wheelchair. These failures could place residents at risk for injuries, cross contamination, unwanted infections, and a decrease in quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure based on the comprehensive assessment of a resident, the facility ensured a resident with pressure ulcer received necessary treatment and services consistent with professional standards of practice, to promote healing, prevent infection, and prevent new pressure ulcers from developing for 1 of 8 residents (Resident #3) reviewed for pressure ulcers, 1. The facility did not have Dakins solution (diluted bleach used to clean wounds) available for Resident #3's wounds to right and left ischial (a bone you sit on that fuse to form the hip bone), and sacrum (a large, triangular-shaped bone located at the base of the spine). 2. The Wound Care Nurse did not clean Resident #3's wound to prevent introducing bacteria into the wound bed. 3. [...]

Inspectors wroteBased on observation, interview, and record review, 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 and communicable disease and infections for 2 (Resident #49 and Resident #117) of 8 residents whose care was reviewed for infection control in that: 1. The facility failed to have Infection Control Signage regarding EBP on 05/20/2025 for Resident #49 who had a surgical wound to his right great toe . 2. Resident #117's urinary catheter tubing was observed touching the floor on 05/20/2025 and 05/21/2025. This failure placed residents at risk for infections and decrease in quality of life.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide a safe functional, sanitary, and comfortable environment for residents, staff, and the public for 1 (Smoking Area) of 2 facility areas observed for sanitary environment. The facility failed to ensure good general safety precautions were in place when trash from the facility nursing department and biohazard boxes were seen placed on the ground against the fenced enclosure/ smoking area by the facility kitchen where residents went to smoke on 05/20/2025. This failure could cause residents to be exposed to pest control issues and hazardous waste.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents receive services in the facility with reasonable accomodation of resident needs and preferences for 1 (Resident #52) of 16 residents reviewed for services with reasonable accomodation. -Resident #52's call light was observed behind a bedside table and on the floor out of his reach while he was in bed on 05/20/2025. This failure could lead to residents not being able to request and receive prompt medical care and result in injury and harm.

Inspectors wroteBased on interview and record review the facility failed to ensure within 14 days after a facility completed a resident assessment, a facility must electronically transmit encoded, accurate, and complete MDS data to the CMS System for 1 of 2 residents (CR #25) reviewed for MDS transmission . The facility failed to transmit a completed Discharge MDS assessment for CR #25 within 14 days of completion. This failure could place residents at-risk of not having their assessment and care plan completed timely, which could result in denial of services and or payment for services.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 8 residents (Residents #3 and #117) reviewed for Foley catheter care. 1. CNA U and CNA VT failed to place Resident #3 Foley catheter bag below the bladder when providing Foley catheter care. 2. The facility failed to ensure Resident #117 catheter tube did not touch the floor while he self-propelled himself in his wheelchair around the facility. These failures could place residents at risk for infections which included urinary tract infection, discomfort, and decrease in quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding which included but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 of 3 residents (Resident #16) reviewed for enteral nutrition. The facility failed to ensure RN S did not push air into Resident #16 when she checked for placement during medication administration. This failure could place residents at risk for complications, aspiration and pneumonia.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 2 (Resident # 2 and #22) of 7 residents reviewed for pharmacy services. 1. The facility ensured Resident 2 breathing treatment was not left for Resident #2 to administer the treatment by himself on 05/20/2025. 2. The facility failed to ensure MA C observed Resident #22 take one of the medications MA C administered to Resident #22 during medication administration on 05/21/2025. The deficient practice could place residents at risk of not receiving the therapeutic effects from their medications as intended by the prescribing physician order.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 11%, based on 3 errors out of 26 opportunities, which involved 2 (Residents #22 and Resident #16) of 7 residents reviewed for medication errors. The facility failed when: 1-MA C was about to mix Polyethylene Glycol Powder which was not measured as ordered for Resident #22 during medication administration on 05/21/2025. 2-RN S left substantial amount medication residue for Amlodipine besylate 5 mg and sennosides 8.6 mg was left on the medication cups after medications was administered through a g - tube to Resident #16 on 05/21/2025. These failures could place residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health.

Inspectors wroteBased on observation, interview and record review, the facility failed to adequately equip to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside for 2 (Residents #26 and #52) of 16 residents reviewed for call lights. 1. Resident #26's call light had exposed wiring, with the inner black and red wires separated from the white outer coating. 2. Resident #52's call light was observed behind a bedside table and on the floor out of his reach while he was in bed on 05/20/2025. This failure could lead to residents not being able to request and receive prompt medical care and result in injury and harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision to prevent and accidents for one (Resident # 1) of 5 residents reviewed for supervision. The facility failed to provide adequate supervision to Resident # 1 to prevent injury of unknown origin (a physical injury where the cause or source is not known, or could not be explained, and raises suspicion of abuse or neglect due to the injury's size, location, or circumstances) which resulted in Resident # 1, who is totally dependent on staff for care, having a mildly displaced fracture of the fourth proximal phalanx (the bone closest to the base of a finger) on 5/7/2025 when a family member visited and noted a swollen finger. Resident # 1 did not leave the facility on an outing and only facility staff provided care to Resident # 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each residents had the right to be free of abuse for 2 of 9 residents (Resident #2 and Resident #3) reviewed for resident-to-resident abuse. The facility failed to ensure Resident #2 was free from abuse when CR#1 banged Resident #2's head on the floor causing a laceration to the back of his head and requiring 32 staples. The facility failure to ensure residents were free from abuse due to Resident #3 and Resident #4 having an altercation resulting in Resident #3 sustaining a cut to the chin by Resident #4. An Immediate Jeopardy (IJ) was identified on 09/27/2024 at 4:24pm. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility's assessment tool for 2 of 19 residents (Resident #2 and Resident #3)reviewed for sufficient staff. -The facility failed to ensure adequate supervision was provided for Resident #3's wandering to prevent resident-to resident altercations between Residents #3 and #4 on 8/10/24 and 9/2/2024 in which Resident #3 sustained injuries to his face. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to ensure the MDS assessment accurately reflected the resident's status for 2 of 6 (Resident #2 and Resident #3) reviewed for MDS assessment accuracy in that: -The facility failed to ensure Resident #2's MDS accurately addressed his wandering. -The facility failed to ensure Resident #3's MDS accurately reflected his wandering. This failure placed residents at risk of not receiving care and services to meet the needs of the residents. Findings Included: Resident #2 Record review of Resident #2's face sheet revealed he was a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure personnel provided basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel for 1 of 19 residents (CR #1) reviewed for CPR. 1. Laundry Aide D failed to call a code blue or express CR #1 experienced a medical emergency when she requested assistance in the locked memory care unit after CR #1 was noted to be unresponsive on 05/18/2024. This led to a delay of at least three minutes before nursing staff arrived to assess CR #1, who died shortly after arrival to the ER. 2. CNA A initiated CPR with improper chest compressions prior to knowing if CR #1 was full code and prior to checking for a pulse while he was still sitting unresponsive in his wheelchair on 05/18/2024. 3. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure pain management was provided to residents who required such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 6 residents (Resident #1) of 6 reviewed for pain management in that: -The facility failed to address Resident #1's pain in her left leg and ankle after falls on 1/31/24, 2/8/24 and 4/2/24 and unresolved pain relief from the Tylenol and Tramadol prescribed. This failure could place residents at risk for unnecessary pain, discomfort, and decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to develop, implement, and maintain an effective compliance and ethics program that is likely to be effective in preventing and detecting criminal, civil, and administrative violations and promoting quality of care in that: The facility failed to conduct effective training and education to staff. The facility failed to have a designated compliance liaison. The facility failed to have a designated compliance officer that was not a subordinate to a chief operating officer (Regional Director of Operations). The facility failed to have a compliance committee. The facility failed to promote and create an environment where staff are comfortable reporting and talking to State without fear of retaliation. These failures could place residents at risk of diminished quality of care, violation of their rights, and repeated violations.

Inspectors wroteBased on interview and record review the facility failed to implement a system to effectively communicate the compliance and ethic program's standards, policies, and procedures through a training program for 8 (Administrator, DON, MDS Coordinator, SW, Charge Nurse A, CNA G, CNA F and Treatment Nurse) of 8 employees. The facility failed to ensure compliance and ethics training was provided to the Administrator, DON, MDS Coordinator, SW, Charge Nurse A, CNA G, CNA F and Treatment Nurse. The facility failed to maintain compliance and ethics training records for all employees. This failure could affect residents and place them at risk of poor care or victimization due to lack of staff training.

Inspectors wroteBased on interview and record review the facility failed to ensure the residents were given the right to participate in the development and implementation of their plans of care for 1 of 6 (Resident #1) residents reviewed for participating in care planning. The facility did not invite Resident #1 to participate in resident care planning meetings or schedule/reschedule the care planning meetings so Resident #1 could be included in discussing her care and appropriate interventions. This failure could place residents at risk for a loss of independence, psychosocial well-being and the opportunity for them or responsible party to participate in the planning of their care. Findings Included: [...]

Inspectors wroteBased on observation, record review and interviews the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodations of residents' needs and preferences for 1 of 6 residents(Resident #1) reviewed for resident rights. The facility failed to ensure: 1. Resident #1's orthopedic appointment was scheduled as ordered by the ER physician on 2/11/2024 after a fall that resulted in a fracture to her ankle, delaying necessary evaluation and further treatment. 2. Resident #1 was accompanied by staff to her orthopedic appointment on 3/26/2024, as resident had requested, and instead cancelled it due to no staff being available. This failure placed residents with scheduled appointments at risk of not receiving necessary care that could have caused further injury, pain and infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment plan of care for 2 of 10 residents (Resident #1, Resident #2) reviewed for comprehensive care plans. The facility failed to: 1. Appropriately care plan for falls when Resident #1 had multiple falls prior to and on 4/2/24. 2. Appropriately care plan for falls when Resident #2 had a fall on 05/06/24. These failures could place residents at risk of not having their care needs met, not being seen by specialty physicians, not receiving treatments, which could cause a decline in physical and psychosocial health.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide diagnostic services to meet the needs of its residents in a timely manner for 2 of 6 (Resident #1 and Resident #3) residents review for radiology services. -The facility failed to ensure the lab company provided Resident #1's x-ray STAT as ordered by physician on 2/8/2024, causing a delay in treatment and services. The lab company did the x-ray on 2/11/2024, 3 days after the fall. - The facility failed to obtain a chest x-ray for Resident #3 when he was experiencing pain. These failures could place residents at risk of delayed diagnosis and medical treatment to prevent complications and injuries. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest, practicable physical, mental, and psychosocial well-being of each resident for 1 of 10 residents (Resident #1) reviewed for administration. The Administrator failed to ensure the DON was trained on how to carry out her responsibilities in the areas of staff training/monitoring and supervision, to provide accurate and timely pain assessments, ensure timely x-rays are completed, ensure residents attend physician appointments, ensure residents were properly prepared for their medical procedures, and update care plans in a timely manner. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet residents' mental and psychosocial needs, for 2 (Resident #49, Resident #63) of 8 residents reviewed for care plans. -The facility did not care plan Resident #49 for oxygen via nasal cannula PRN. - The facility failed to ensure Resident #63's Comprehensive Care Plan reflected a revision for his slit penis when he came back to the facility from hospital on 5/17/23 with indwelling Foley catheter. This failure placed resident at risk for not receiving oxygen as needed and decrease in quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 of 8 (Resident #32) residents' reviewed for respiratory care. -The NF failed to date Resident #32's breathing mask and store inside of bag. -The NF failed to dispose of Resident #49 humidifier bottle that was dated 03/05/24. These failures placed residents at risk for infections and decrease in quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centerd care plan, and the reisdents' choices, for 1 of 8 (Resident #57)residents feviewed for care. -The NF failed to date Resident #57 IV tubing. -The Wound Care Nurse failed to clean Resident #57's wounds correctly to the lower left extremity to prevent infecting the wounds. -The Wound Care Nurse failed to store the normal saline bottle on the cart, instead took the saline bottle in and out of Resident #57's room during wound dressing changes. These failures placed residents at risk for infections and decrease in quality of life. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and promote healing, prevent infection or deterioration of pressure ulcer, for 1 of 8 (Resident #7) residents reviewed for pressure ulcers. -The Wound Care Nurse failed to clean Resident #7's wound correctly to the sacrum to prevent infecting the wound. -The Wound Care Nurse failed to store the normal saline bottle on the cart, instead took the saline bottle in and out of resident #7's room during wound dressing change. This failure placed resident at risk for infections and decrease in quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one of one resident reviewed for catheter care ( Resident #63). The facility failed to ensure Resident #63's catheter was secured as ordered by a physician. This failure to secure catheters placed residents with urinary catheters at risk for traumatic removal and catheter acquired infections.

Inspectors wroteBased on observation and interview the facility failed to dispose of garbage and refuse properly for 1 of 1 dumpster reviewed for Food and nutrition services. -The facility failed to ensure the dumpster lids and doors were secured. This failure could place residents at risk of infection from improperly disposed garbage.

Inspectors wroteBased on observation, interview, the facility failed to ensure the drugs and biologicals used in the facility were secured in locked compartments, labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 1 medication carts (AB Skilled nurse medication cart) and 1 of 1 medication room reviewed for drug labeling and storage. - The facility failed to ensure a previously opened Insulin pen stored on AB Skilled nurse medication cart had an open date labeled on the pen to track expiration of insulin device. - The facility failed to ensure a previously opened Insulin pen stored on AB Skilled nurse medication cart had an expired date labeled on the pen. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide food prepared in a form designed to meet individual needs for 2 (Resident's #32 and #49) of 2 residents reviewed for food preparation. -The facility failed to prepare food in a form designed to meet Resident's #32 and #49 needs. This failure could place residents at risk of aspiration pneumonia, choking, and diminished resident's quality of life.

Inspectors wroteBased on interview and record review, the facility failed to implement an antibiotic stewardship program that included antibiotic use protocols for 9 of 9 months (May 2022 through January 2023) reviewed for Infection Control Tracking and Trending. -The facility did not implement the antibiotic orders protocol in their Antibiotic Stewardship policy. -The facility was missing the Tracking and Trending Logs. -The facility had missing information on the Tracking and Trending Logs as to the outcome of the antibiotic use (if the infections were resolved or not). -The facility did not implement the 72-hour Antibiotic Time Out protocol in their Antibiotic Stewardship policy. These failures could place residents with infections at risk for unnecessary antibiotic use and increased infections that are resistant to antibiotics.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the right to formulate an advance directive was provided for 1 of 3 residents reviewed for advanced directives. (Resident #25) -The facility did not have a valid Out of Hospital-Do Not Resuscitate (OOH-DNR) for Resident #25. This failure could place residents at risk of lifesaving procedures performed against their wishes resulting in bruising, broken ribs, electrical shocking of the heart, having a tube placed in the throat and provided artificial breathing methods, and possibly being brought back to life in an unaware and unresponsive state.