Paradigm at Woodwind Lakes

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that drugs and biologicals were stored in locked compartments under proper temperature controls, limited access, for 1 of 2 (Hall A) medications storage rooms reviewed for proper medication storage.-Medication storage room on Hall A had 4 bags of 50ml normal saline mixed with the antibiotic medication daptomycin 500mg sitting out on the countertop. The label on the outside of the bag read to refrigerate upon arrival. This failure could place residents at risk for infection, IV contamination, and treatment of the medication not being effective. Record review of Resident #71 face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] and again on 05/12/26. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that food was prepared, distributed, and served food in accordance with professional standards for food service safety in one of one kitchen in that. _The facility failed to ensure that equipment was cleaned. [...]

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 infection for 2 of 6 residents (Resident #7 and Resident #4) and 2 of 2 staffs (CNA T, CNA B ) reviewed for infection control.-The facility failed to ensure CNA B donned PPE including gloves and gown before preforming incontinent care to Resident #7 with EBP sign posted on the entrance door on 6/3/2026. -The facility failed to ensure CNA T donned PPE including gloves and gown before performing incontinent care to Resident #4 with EBP sign posted on the entrance door on 6/3/2026. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents have a right to a dignified existence and treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 2 (Resident #4 and Resident #7) of 8 residents reviewed for dignity.- C NA B did not knock on the residents' door prior to entering and did not provide Resident #7 privacy during incontinent care with Resident #116 (roommate) in the room on 06/03/2026.- C NA T did not knock on the residents' door prior to entering and did not provide Resident #4 privacy during incontinent care with Resident #25 (roommate) in the room on 06/03/2026. These deficient practices could lead to psychosocial harm due to feelings of low self-esteem and/or embarrassment regardless of resident cognition.

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #77) of 5 residents reviewed for comprehensive care plans. Resident #77's comprehensive care plan did not include all care areas triggered on the resident assessment. This failure could place all residents in the facility at risk of not receiving proper care to develop and improve their mental, physical and psychosocial well-being. Record review of Resident #77's admission face sheet revealed Resident # 77 was a [AGE] year-old male who was admitted on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for one resident (Resident #99), of four residents reviewed for ADLs. The facility failed to provide nail care to Resident #99. This deficient practice could place residents at risk of skin breakdown and reduced feelings of self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 6 residents (Resident #7 and Resident #4) reviewed for incontinent care. -The facility failed to ensure CNA B cleaned Resident #7's buttocks before putting on a clean brief during incontinent care on 6/3/26. -The facility failed to ensure CNA T cleaned Resident #4 's buttocks before putting on a clean brief during incontinent care on 6/3/26. This failure could place residents at risk for pain, infection, injury, and hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 2 of 11 (Residents #42 and #110) residents reviewed for respiratory care. -The facility failed to ensure Resident #42's oxygen was administered at the correct setting of 2-3 liters per minute on 06/02/2026.-The facility failed to ensure Resident #110's oxygen was administered at the correct setting of 2-3 liters per minute on 06/03/2026. These failures could place residents who receive respiratory care at an increased risk of developing respiratory complications and a decreased quality of care. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to assist residents in obtaining routine and 24-hour emergency dental care and in making appointments for 1 of 4 residents (Residents #36) reviewed for dental care. -The facility failed to assist Resident #36 in making their respective follow-up dental appointments. These failures could place residents at risk of oral complications, dental pain, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had the right to formulate an advance directive for 4 of 8 Residents (CR#1, Resident #1, Resident #2, Resident #3) reviewed for Advance Directives. - The facility failed to ensure there was a system in place to ensure all residents wishes for advanced directives were implemented and discrepancies regarding DNR wishes were addressed immediately upon admission.- The facility failed to clarify discrepancies in CR #1's wishes of DNR when she admitted on [DATE]. On [DATE] CR #1 was found unresponsive and received CPR from 06:26 AM to 07:04 AM in the facility and until 07:28 AM in the hospital until the POA notified the staff of the DNR wishes and rescue efforts were stopped. CR #1 expired at 07:28 AM. [...]

Inspectors wroteBased on interview and record review the facility failed to inform residents, both orally and in writing in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility for 1 of 8 residents (CR #1) reviewed for resident rights. - The facility failed to provide/communicate to CR#1's and/or her RP the contents of admissions packet which provided the resident's rights, the rules governing resident conduct, their responsibilities during their stay at the facility, and acknowledgement of advance directives when the resident admitted on [DATE]. On [DATE] CR #1 received CPR after she was unresponsive, even though her wishes were DNR. This deficient practice could place residents at risk of not being aware of their rights, responsibilities, and the facility's policies.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 5 residents (Resident #3) reviewed for quality of care. LVN A and CNA B failed to prevent Resident #3 from an unwitnessed fall while being unsupervised in the memory care unit's dining room. Resident #3 sustained a hematoma to the right side of the forehead, which resulted in hospital treatment. This failure could place residents at risk for harm, pain, and injury. Findings Include:Record Review of Resident #3's face sheet dated 03/21/2026, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Resident #3's diagnoses included Dementia with psychotic disturbance (visual and auditory hallucinations or delusions related to Dementia); [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 10 residents (Resident #2) reviewed for quality of care. The facility failed to ensure proper care and monitoring of an indwelling urinary catheter, which resulted in Resident #2's penis slit increasing from 0.3 cm in length by 0.1 cm in width to 1.5 cm in length by 0.5 cm in width, and the color of the slit area was beefy red and slightly bleeding.2. The facility failed to ensure proper care and monitoring of Resident #2's indwelling urinary catheter, which resulted in urine draining onto the resident's incontinent brief. These failures could have placed residents at risk for pain, infection, injury, and hospitalization. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment for 2 of 3 (Resident #1 and Resident #3) residents reviewed for comprehensive assessments.1. The facility failed to ensure that Resident #1's care plan included the physician ordered hand splint interventions for his hand contractures, and the implementation of the device.2. The facility failed to implement the care plan interventions for Resident #3's persistent wandering when she had an unwitnessed fall and sustained a hematoma to the right side of the forehead, which resulted in hospital treatment. [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure that each resident received adequate supervision to prevent accidents for 2 of 8 residents (Resident #60 and Resident #134) reviewed. The facility failed to ensure adequate supervision to prevent accidents for Resident #60 and Resident #134 when they were smoking outside without staff supervision. This failure placed the residents at risk for burns, injury, and fire hazards.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 10 residents (Resident #12) reviewed for incontinent care. 1. CNA AA failed to ensure Resident #12's indwelling Foley catheter tubing was below the bladder while assisting LVN CC during pressure ulcer treatment on 01/7/26. 2. The facility failed to ensure Resident #12's indwelling catheter was secured on 1/7/26. Resident #12 had a slit on his penis measuring 0.3 cm length by 0.1 cm width that was identified by the Surveyor on 1/7/26. These failures could place residents at risk for pain, infection, injury, and hospitalization.

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 8 (Resident #54) residents reviewed for comprehensive assessments. The facility failed to ensure that Resident #54's care plan documented interventions for hand contractures. This deficient practice could place residents at risk of not receiving proper care and services. Findings Included:Record review of Resident #54's face sheet dated 01/07/2026 revealed a [AGE] year-old admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 (Resident #10) of 2 residents reviewed for enteral nutrition. The facility failed to always provide the abdominal binder as a supportive device per physician orders to help prevent dislodgment of Resident #10's G-tube (Gastrostomy feeding tube). These failures could place residents with G-tubes at risk of injuries, hospitalization, and death. Record review of Resident #10's face sheet dated 01/08/2026 revealed a [AGE] year-old admitted to the facility on [DATE] and initially admitted on [DATE]. [...]

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, and the residents' goals and preferences for one of one residents reviewed for Tracheotomy care (Resident #1) The facility failed to ensure LVN AA used sterile technique and checked oxygen saturation before and during tracheostomy suctioning for Resident #1 on 01/09/26. These failures placed residents with tracheostomy requiring suctioning at risk for respiratory infections, hospitalizations, and a decline in their quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records were kept in accordance with professional standards and practices and were complete and accurately documented for 1 of 5 residents (Resident #125) reviewed for accuracy of records. The facility failed to ensure Resident #125's bath or shower was documented as given on 1/1/26, 1/3/26 and 1/6/26 in her electronic chart. These failures could place residents at risk for improper care due to inaccurate records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 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 2 of 11 residents (Resident #12 and Resident #6) observed for infection control. 1. The facility failed to ensure C.NA AA and C.N A BB used the required PPE for Resident #12, who was on enhanced barrier precautions while performing incontinent/indwelling Foley catheter care on 01/07/26. 2. CNA E failed to perform hand hygiene with glove changes during perineal care on Resident #6. 3, CNA E donned gloves from out of her pocket during perineal care on Resident #6. These failures could place the residents at risk of cross-contamination and development of infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of misappropriation of property was reported immediately but not later than 24 hours after the allegation was made to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 2 of 2 residents (CR #142 and Resident# 134) reviewed for reporting. The Prior administrator failed to report to the State Survey Agency the incident of missing money for Resident #134 on 7/22/2025 and CR #142 on 6-9-25. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure Residents receive adequate supervision and assistance devices to prevent accidents for Resident # 1. The facility failed to ensure CNA A properly transferred Resident # 1 on 07/16/2025. This failure could place Residents at risk of being injured.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of 3 of 8 residents (Residents #32, #70 and #60) and failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for 2 of 5 medication carts (LEC MA cart and East Front Nurse cart) reviewed for pharmacy services. The facility failed to ensure the LEC medication aide's cart had accurate narcotic counts for Residents #32 and #70 on 8/14/25. MA W stored Resident #32's Lorazepam (a narcotic used to treat anxiety) on the medication cart incorrectly after not immediately wasting it with a nurse on 8/14/25. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain and effective pest control program, so the facility was free of pest and rodents for 1 of 1 kitchen and 2 of 2 dining rooms reviewed for environment. - Flies were witnessed on residents dining plates, before food was placed on the plate.- Flies were sitting on residents' food, as they were eating.- A roach was identified in the dining area while residents were eating. These failures could place residents at risk of infection, skin irritation, allergies, which could result in unsanitary living conditions and decline in health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care -plan for the resident, consistent with the resident rights that include measurable objects and timeframes to meet the residents medical, nursing, and mental psychosocial needs that are identified in the comprehensive assessment for 1 of 9 residents (Resident #8) reviewed for comprehensive care plans. The facility failed to: - Update the comprehensive care plan to resident #8 having a 1/4 right rail on the right side of the bed. This failure could place the resident at risk for not obtaining/maintain their highest practicable wellbeing.

Inspectors wroteBased on interview and record reviewed, the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #1) of 5 residents reviewed for quality of care. - Resident #1's Dialysis Hand Off Communication Report forms were not completed or incomplete for 22 out of 23 opportunities. This failure placed residents at risk of unrecognized dialysis complications.

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 one of two residents (Resident #2) reviewed for infection control and prevention, in that: The facility failed to ensure the Wound Care Nurse properly changed gloves during wound care for Resident # 2 on 04/09/2025. This failure placed residents with wounds at risk for infection, prolonged healing, worsening of existing pressure injury, new pressure injury formation and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had a safe, clean, comfortable, and homelike environment for 1 of 6 rooms reviewed for homelike environment. The facility failed on 02/20/2025 to ensure Residents #1 and Resident #2 windows on the secure unit (made of out of plexi glass- plastic glass replacement) were sealed, not broken and free from air entering the room through the window. These failures could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, uncomfortable, and unsafe.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 1 secured unit reviewed for environmental concerns. The facility failed to ensure that floors were clean and devoid of dirt and debris. These failures could place residents at risk of living in an unsafe, unsanitary, and uncomfortable environment.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who are fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 3 of 9 residents (Residents #25, #46, and #437) reviewed for gastrostomy tube management. -The facility failed to ensure Resident's #25, #46, and #437 head of bed (HOB) was elevated at a minimum of 30-degree angle during enteral feeding (a way to deliver food directly to the stomach) via gastrostomy tube (G-tube) (A tube directly inserted through the skin to the stomach to deliver nutrition). -LVN J failed to check for residual before administering medication via G-tube to Resident #25. [...]

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 to meet the needs of 3 of 10 residents (Resident #54, Resident #82 and Resident #98) and 2 of 5 medication Carts (West Front Nursing Cart and East Front Nursing Cart) reviewed for pharmaceutical services. - The facility failed to ensure Resident #98's Pre-Prandial Insulin (insulin taken before a meal) was scheduled and administered with regards to meals and in accordance with manufacturer instructions to administer 15 minutes before or right after a meal. [...]

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 25 % based on 7 errors out of 27 opportunities, which involved 2 of 4 residents (Resident #25 and Resident #93) reviewed for medication errors in that: - MA G failed to administer medication as ordered to Resident #93 by administering Sennoside 8.6 mg, a stool softener, instead of Sennoside 8.6 mg- Docusate 50 mg as ordered. - LVN J failed to administer medications as ordered to Resident #25 by administering plain Multivitamins instead of Multivitamins w/ Minerals as ordered. [...]

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure a comprehensive care plan was developed for 1 of 22 residents (Resident #36) reviewed for care plans, in that: Resident #36 was not care planned for oxygen therapy. This failure could place residents at risk for not receiving adequate medical care.

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure 1 of 2 residents (Resident #36) was assessed for accident supervision, in that: Resident #36 was observed with full size rails installed on her bed and did not have an assessment for bed rail entrapment risk. This failure could place residents who have bed rails installed at risk for entrapment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure complete medical documentation was kept in accordance with professional standards for 1 of 3 residents (Resident #102) reviewed for weight loss in that: Resident #122 did not have weights documented after admission and for a span of nearly two months. This failure placed residents with nutrition-related risks at risk of not having their nutritional needs addressed in a timely manner.

Inspectors wroteBased on observation, interview and record review the facility failed to clean and serve in dishes that were in accordance with professional standards for food service safety for 1 of 1 Kitchen observed in that: 1. The facility failed to adequately clean drinking glasses that were used for serving drinks. 2. The facility served drinks in glasses that had dried, hard white residue around the rims and food debris inside of them. 3. The facility failed to adequately clean plates that were used to serve food to residents. These failures could place residents at risk for food contamination and food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain an infection prevention program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 6 of 12 residents (Residents #1, #2, #3, #4, #5, #6) reviewed for infection control. -CNA A failed to change gloves from dirty to clean during incontinent care on Resident #1. -CNA B failed to distribute unpackaged cookies using gloved hands or paper towels to Residents #2, #3 and #4. -MA D failed to disinfect multiuse blood pressure cuff between 2 residents. These failures could place residents who require incontinent care and residents who are given unpackaged foods at risk of cross contamination and infection.

Inspectors wroteBased on interview and record review the facility failed to coordinate an assessment with the Preadmission Screening and Resident Review program (PASRR) under Medicaid to the maximum extent practicable to avoid duplicative testing and effort for 1 of 1 resident (Resident #7) reviewed for PASRR services. The facility failed to submit a NFSS request for nursing facility specialized services in the LTC Online Portal for Resident #7's physical therapy (PT) specialized services by a specific deadline of 06/10/23. This failure could place residents with a positive PASRR evaluation at risk of not receiving specialized PASRR services which could contribute to a decline in physical, mental, psychosocial well-being and quality of life.