Paradigm at the Pines

Inspectors wroteBased on interviews and record review, the facility failed to consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility for 16 out of 16 anonymous residents during a confidential meeting who were reviewed for resident rights. The facility failed to ensure the resident council food grievances were promptly resolved. This failure could place residents at risk for a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received and the facility provided food and drink that was palatable, attractive, and at a safe and appetizing temperature for 8 of 16 residents (Resident #15, Resident #20, Resident #24, Resident #27, Resident #37, Resident #38, Resident #48 and Resident #49) reviewed for food and nutrition services. 1. The facility failed to ensure residents received food that tasted good. 2. The facility failed to ensure residents received food with an appetizing appearance, texture, and appropriate temperature. These failures could place residents at risk of weight loss, altered nutritional status and diminished quality of life. 1. [...]

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 of communicable diseases and infections for 1 of 3 hallways (D Hall) and 1 of 1 (Resident #16) reviewed for infection control practices. 1. The facility failed to ensure LVN E performed hand hygiene between each meal tray while passing the lunch meal trays on 12/08/25. 2. The facility failed to ensure CNA D changed her gloves and performed hand hygiene during Resident #16's incontinent care on 12/09/25. These failures could place residents at risk for cross contamination and an increased risk of infection, or the spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident had the right to a safe, clean, and comfortable homelike environment for 1 of 16 residents (Resident #40) reviewed for physical environment. The facility failed to ensure Resident #40's room was cleaned and in good repair. This failure could place residents at risk for a decreased quality of life and an unsanitary environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as was possible for 1 of 3 Halls (Hall C) reviewed for accidents and supervision. The facility failed to ensure an unsecured shower room did not contain bath wash, disinfectant, which was labeled Keep out of the reach of children and a package of disposable razors This failure could place residents at risk for accidents that could lead to injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident is offered sufficient fluid intake to maintain proper hydration and health for 1 of 16 resident (Resident #39) reviewed for hydration. The facility failed to ensure Resident #39 had a water pitcher at his bedside on 12/08/25, 12/09/25, and 12/10/25. This failure could place residents at risk for decreased quality of care and dehydration.

Inspectors wroteBased on interview and record review the facility failed to provide pharmaceutical services including procedures that assured the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals to meet the needs of each resident and determined that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled for 1 of 3 residents (Resident #46) reviewed for pharmacy services. The facility failed to ensure Resident #46's as needed Tylenol #3 (narcotic pain medication) was signed out in the electronic medical record, when it was given on 12/02/25, 12/04/25, and 12/06/25. This failure could place residents at risk for medication errors and loss of medications through drug diversion.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident received and the facility provided food that accommodated the resident allergies, intolerances and preferences 1 of 16 residents (Resident #19) reviewed for food and nutrition services. The facility failed to ensure Resident #19's food preferences and listed food allergy were honored. This failure could place residents at risk for dissatisfaction, poor intake, and/or weight loss. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to establish policies, in accordance with applicable, Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that also take into account nonsmoking residents for 1 of 2 residents (Resident #5) reviewed for smoking and smoking policy. The facility failed to complete a quarterly smoking assessment for Resident #5 per facility policy. This failure could place residents at risk of an unsafe smoking environment and injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 3 residents reviewed for accidents and supervision. (Resident #1)The facility failed to provide adequate supervision for Resident #1 who was assessed as a high risk for elopement. On 03/23/25 CNA B who was assigned to cover the unit left the unit leaving the residents unattended. Resident #1 eloped from the unit and was found at his previous home address sitting on the porch steps approximately 1 mile from the facility. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 03/23/25 and ended on 03/27/25. The facility had corrected the non-compliance before the survey began. This failure could prevent residents from receiving appropriate supervision which could lead to resident sustaining serious injury or harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the residents' right to be free from physical abuse for 4 of 6 residents (Resident #2, Resident #3, Resident #4 and Resident #5) reviewed for abuse. 1. The facility failed to ensure Resident #2 was free from physical abuse when Resident #2 was slapped on the neck by Resident #3 on 01/21/2025. 2. The facility failed to ensure Resident #2 was free from physical abuse when Resident #2 was punched on the arm by Resident #3 on 05/18/2025. 3. The facility failed to ensure Resident #5 was free from physical abuse when Resident #4 pushed Resident #5 causing him to fall on 07/02/2025. These failures could place residents at risk for emotional distress, fear, decreased quality of life and further abuse.

Inspectors wroteBased on interview and record review, the facility failed to have evidence that all allegations of abuse, neglect, exploitation, or mistreatment, were thoroughly investigated for 4 of 6 residents (Resident #2, Resident #3, Resident #4 and Resident #5) reviewed for abuse and neglect. 1. The facility did not thoroughly investigate an incident in which Resident #2 was slapped on the neck by Resident #3 on 01/21/2025. 2. The facility did not investigate an incident in which Resident #2 was punched on the arm by Resident #3 on 05/18/2025. 3. The facility did not thoroughly investigate an incident in which Resident #4 pushed Resident #5 causing him to fall on 07/02/2025. This failure could place residents at risk for abuse/neglect and could lead to a diminished quality of life and psychosocial harm.

Inspectors wroteBased on interviews, and record review, the facility failed to review and revise resident's comprehensive care plans by the interdisciplinary team after each assessment to reflect the current condition for 2 of 12 (Resident #2 and Resident #3) residents reviewed for comprehensive care plans. The facility failed to ensure Resident #2's care plan was updated to indicate Resident #2 had received aggression during a resident-to-resident incident on 01/21/2025 and 05/18/2025. The facility failed to ensure Resident #3's care plan was updated to indicate Resident #3 had an incident of resident-to-resident aggression on 01/21/2025 and 05/18/2025. This deficient practice could place residents at risk of not receiving appropriate interventions to meet their current needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse were reported, immediately but not later than 2 hours after the allegation was made, if the events that cause the allegation involves abuse or results in serious bodily injury, to the State Survey Agency for 1 of 5 residents (Residents #2) reviewed for reporting allegations of abuse. The facility failed to report an allegation of abuse to the state agency within 2 hours after Resident #3 punched Resident #2 in the arm on 05/18/2025. The failures could place residents at risk of not having allegations reported within the required timeframes.

Inspectors wroteBased on interview and record review, the facility failed to establish a system of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and determine that drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 1 of 4 residents (Resident #6) reviewed for controlled medications. * LVN X and RN Y did not count the narcotic medications during the shift change to ensure the count was correct and all narcotics had an Inventory Sheet. * Resident #6's hydrocodone 5 mg /acetaminophen 325 mg (narcotic pain medication for moderate or severe pain) were not counted and did not have an Inventory Sheet on 10/04/24. This failure could place residents at risk for medication overdose, medication under-dose, ineffective therapeutic outcomes, and drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received and the facility provided food prepared by methods that conserve nutritive value, flavor, and appearance and were palatable, attractive, and at a safe and appetizing temperature for 1 of 1 kitchen reviewed for food and nutrition services. The facility did not ensure the chicken wrap and potato salad served for lunch on 10/01/24 were palatable. These failures could place the residents at risk of a decline in their satisfaction and weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions for 1 of 1 kitchen reviewed for dietary services. The facility failed to ensure food items were properly labeled with product and expiration date in the freezers. The facility failed to properly close items stored in the freezers. These failures could place residents, who ate meals prepared in the kitchen, at risk for food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received an accurate assessment, reflective of the resident's status for 2 of 17 residents reviewed for accuracy of assessments. (Resident #s 5 and 54) The facility did not accurately complete the MDS assessment to indicate Resident #5 was receiving an anticoagulant medication. The facility did not accurately complete the MDS assessment to indicate Resident #54 was receiving an anticoagulant medication. This failure could place the residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being.

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 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 17 residents. (Resident #5) The facility failed to develop a care plan for Resident #5's anticoagulant (blood thinner) medication, Eliquis. This failure could place the residents at risk of not receiving care and services to maintain their highest level of well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) in 1 of 3 medication carts reviewed (Hall B and right side of Hall C Nurse medication cart) in that: An insulin pen of Insulin Glargine yfgn (used to lower blood sugar) with an open date of 08/03/24, had been expired for 60 days and not removed from use. This failure could place residents at risk for accidents, hazards, and not receiving therapeutic effects of medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the menu was followed for 1 of 3 meals reviewed for menus and nutritional adequacy. (Lunch meal 10/01/24) The facility did not ensure the recipes were followed for the chicken wrap and potato salad served for lunch on 10/01/24. This failure could place residents at risk of not having their nutritional needs met.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect a resident's right to be free from abuse for 2 of 11 residents reviewed for abuse. (Resident #1 and #2) The facility failed to protect Resident #1 from inappropriate sexual touching by Resident #2. This failure could place residents at risk of for psychosocial harm and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure they had a full time DON and failed to ensure the had an RN for 8 consecutive hours 7 days a week for 6 of 6 months reviewed for RN coverage. * The facility did not have a full-time DON between 9/02/23 and 9/18/23. * The facility did not have RN coverage for 8 consecutive hours on Saturday and Sunday. These failures could place residents at risk of lack of nursing oversight and a higher level of care. 1. During an interview upon entrance on 09/18/23 at 08:46 a.m. the ADM said she had no full time DON and will call to try and get interim back. During an interview on 09/19/23 at 10:35 a.m. the ADM said the previous DON's last day was 07/21/23. She said the Interim DON originally began on 07/24/23. She said the Interim DON was off on 07/25/25 but they did have RN coverage for the day. [...]

Inspectors wroteBased on interview and record review, the facility failed to employ sufficient staff with appropriate competencies and skill sets to carry out the functions of the food and nutrition service for 1 of 1 facility kitchen. The facility failed to designate a person to serve as the Dietary Manager who met the required qualifications. The facility designated Dietary Manager did not have a Dietary Managers certification or any other qualifying credentials. This failure could place residents at risk for the spread of foodborne illness and residents not having their nutritional needs met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the kitchen reviewed for dietary services. The facility failed to prevent the following: Two of 4 freezers had 3-to-4-inch layer of buildup of ice. The juice dispenser nozzle (gun) had thick buildup of black and red substance on the inside of the nozzle. The deep fryer contained very dark grease with particles of food debris and had an odor. Food items were not properly labeled with product and expiration date in the refrigerator. The grates on the stove had buildup of black substance. These failures could place residents, who ate meals prepared in the kitchen, at risk for food borne illness.

Inspectors wroteBased on interview and record review the facility failed to follow guidelines for mandatory submission of staffing information based on payroll data in a uniform format. The facility failed to submit direct care staffing information on the schedule specified by CMS (Centers for Medicare and Medicaid Services), but no less frequently than quarterly for 1 of 3 quarters reviewed for payroll data information. *The facility failed to submit staffing information to CMS for the 3rd quarter of the fiscal year 2023. This failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment.

Inspectors wroteBased on interview and record review the facility failed to ensure assessments accurately reflected the resident status for 5 of 5 residents (Residents #9, #18, #31, #40, and #58) reviewed for MDS assessment accuracy. The facility did not ensure Residents #9, #18, #31, #40, and #58 assessment was accurately coded to reflect falls since the previous assessment. This failure could place residents at risk for not receiving care and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards 2 of 2 residents reviewed for smoking safety assessments and 7 of 7 residents reviewed for fall risk assessments. The facility did not have Smoking-Safety Screens completed for Residents #9, and #13. The facility did not have Fall Risk Assessments completed for Residents #9, #18, #29, #31, #40, #54, and #58 after they had a fall. These failures could place residents at risk of harm or injury and contribute to avoidable accidents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents receiving enteral feeding received appropriate care and services to prevent complication of enteral feeding for 3 of 3 residents (Residents #14, #44, and #57) reviewed for enteral feeding. The facility failed to initiate dietician recommendations for Resident #14. LVN F force flushed water through Resident #44's G-tube that was clogged. LVN G failed to check Resident #57's G-tube placement by aspirating for residual feeding before enteral administration of medications. These failures could place residents receiving enteral nutrition and medications at increased risk of not receiving the proper nutrition, infection, and aspiration.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the menu met the nutritional needs of residents in accordance with established national guidelines, be prepared in advance and was followed for two of three meals (lunch on 09/18/23 and breakfast on 09/19/23) reviewed for food and nutrition services. The facility failed to ensure the menu was followed for the lunch on 09/18/23 The facility failed to ensure the menu was followed for the breakfast meal on 09/19/23 These deficient practice could place residents at risk of dissatisfaction, poor intake, and/or weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide food in a form designed to meet individual needs for reviewed for food form. The facility failed to ensure the residents who required a pureed textured diet, received the appropriate food form to meet their needs on 9/19/23 for the noon meal. The pureed broccoli had small pieces and strings of the broccoli was not fully pureed and smooth consistency. This failure could place the residents at risk of aspiration and choking.

Inspectors wroteBased on interview and record review, the facility failed to notify the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in the mental or physical condition of a resident who had mental illness or intellectual disability for 1 of 18 residents (Residents #54) reviewed for PASARR. The facility failed to notify the local mental health authority after Resident #54's significant change in mental illness diagnosis following a new diagnosis of psychosis. This failure could place residents requiring PASARR services at risk of not having their special needs assessed and met by the facility.