Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Paradigm At The Pines during CMS and state inspections, most recent first.
Resident council food grievances were not promptly addressed after repeated complaints about meal quality and menu items. Anonymous residents reported bland, cold, repetitive food, hard toast, spicy chili, and requests for fried eggs and other specific foods that were discussed at multiple council meetings without improvement. The AD said food was a constant issue in council meetings, and the Administrator said a grievance form had been completed, but residents stated their concerns were not resolved.
Meals were not consistently served palatably, attractively, or at an appetizing temperature. Multiple residents with diagnoses including depression, anxiety, dysphagia, stroke, and malnutrition reported food that was too salty, bland, cold, dry, hard, or otherwise unappetizing, and surveyors observed undercooked-looking cornbread, bland Shepherd's Pie, hard fruit, dry biscuits, and cold eggs. A resident also reported a piece of plastic in his peaches, and staff interviews confirmed ongoing complaints about seasoning, texture, and meal quality.
An LVN passed meal trays to multiple resident rooms without performing hand hygiene between residents, and a CNA provided incontinent care to a resident with severe cognitive impairment using the same gloves throughout the task without hand hygiene or glove changes when moving from dirty to clean. The DON stated staff were expected to follow hand hygiene and glove-change practices during meal service and incontinent care, and the Administrator stated staff were expected to follow infection control policies and procedures.
A resident admitted with tongue cancer was found in a room with a running toilet, a faucet that sprayed water onto the surveyor, dirty window areas with brown buildup, warped blinds, and wall damage with missing paint and gouges. The resident said she had reported the issues but they had not been fixed, and staff interviews showed no work order had been entered for the room.
Unsecured Shower Room Contained Chemicals and Razors. The shower room on Hall C was observed unlocked and later found to have a door that would not latch and could be pushed open. Inside a partially broken cabinet were body wash bottles labeled to keep out of reach of children, a package of disposable razors, and a bottle of disinfectant labeled to keep out of reach of children. CNAs stated the room was supposed to be locked when not in use, and the DON said the cabinet was to be kept locked unless staff were giving a shower.
Missing Water Pitcher at Bedside: A resident with severe cognitive impairment, CKD, HF, and rhabdomyolysis did not have a water pitcher at the bedside during multiple observations. Staff stated they passed ice water during shifts and could obtain a pitcher if needed, but the resident’s room remained without one and the DON said nurses were responsible for monitoring bedside pitchers. The facility policy called for cleaned pitchers to be returned to the room and filled with ice water when supplies were available.
A resident with osteoarthritis and pain had an order for PRN Tylenol #3, but doses given by nursing staff were not signed out on the electronic MAR even though they were recorded on the controlled drug record. The DON said narcotic meds were expected to be documented on both the MAR and narcotic count sheet, while an LVN stated she sometimes forgot to complete the MAR documentation after being distracted.
Failure to honor a resident's documented food allergies and preferences. A resident with dementia, paranoid schizophrenia, and major depressive disorder had egg and yeast allergies listed in the EMR and care plan, yet breakfast trays continued to include eggs and the meal ticket did not note an allergy. Interviews showed conflicting information from the resident, family, nursing, and dietary staff about whether eggs were a true allergy or simply a preference, and the dietary card had not been updated. Facility policy required food allergies and individual preferences to be documented, communicated, and reflected on meal tickets.
The facility failed to follow its smoking policy by not completing a required quarterly smoking assessment for a resident who smoked. The resident had diagnoses including dementia, bipolar disorder, and seizures, was listed as a smoker, and was documented as a tobacco user with a BIMS score of 15. The DON stated quarterly assessments were the responsibility of the DON and management team, but only one smoking assessment was found in the electronic record. During observation, the resident was seen outside smoking with staff present and without assistance.
Two residents with severe cognitive impairment and incontinence did not have every episode of incontinence care or checks accurately documented in the electronic medical record. CNA staff reported providing care every two hours but were unable to chart each instance due to recent changes in the EMR system, which limited documentation options. The DON was unaware of the duration of this issue, resulting in incomplete clinical records.
A resident with dementia and a high risk for elopement was left unsupervised when the assigned CNA failed to remain on the secured unit as directed. The resident, who had a history of attempting to leave and expressed a desire to go home, was able to exit the facility by climbing over a fence and was later found at his previous home. Staff interviews and documentation confirmed that the lack of supervision directly led to the resident's elopement.
Multiple residents with severe cognitive and behavioral health conditions were subjected to physical abuse by other residents, including slapping, hair-pulling, punching, and pushing that resulted in a fall. These incidents were witnessed by staff and a contracted lab technician, and occurred despite documented care plans and staff awareness of behavioral risks.
The facility did not thoroughly investigate multiple incidents of resident-to-resident physical altercations, failing to document interviews with other residents to ensure their safety and wellbeing as required by policy. Staff interviews revealed that safe surveys were not consistently conducted or recorded, especially when the social worker was unavailable, despite the residents involved having significant cognitive and physical impairments.
Two residents with severe cognitive impairment were involved in incidents of resident-to-resident aggression, but their care plans were not updated by the interdisciplinary team to reflect these events or add new interventions. Despite staff awareness of the incidents and facility policy requiring care plan revisions after changes in status, the necessary updates were not made, leaving care plans outdated.
A resident with severe cognitive impairment was punched in the arm by another resident with dementia and psychosis. The incident was witnessed by an LVN, reported internally, and documented, but was not reported to the state agency within the required two-hour timeframe as mandated by facility policy. Both the DON and administrator later acknowledged that the event met the criteria for reportable physical abuse, but no report was made to the state agency.
A resident prescribed hydrocodone/acetaminophen for pain management did not have her controlled medication properly counted or documented during shift changes. Nursing staff failed to consistently perform narcotic counts and maintain required inventory sheets, leading to discrepancies in pill counts and missing medication. The facility's policy for shift-to-shift controlled drug reconciliation was not followed, resulting in incomplete records and an inability to accurately account for all controlled substances.
The facility failed to provide palatable and nutritious meals, as residents complained about the taste and edibility of the food. A test tray revealed a chicken wrap that was soggy and unappetizing, and a potato salad with an overpowering garlic flavor. The Dietary Manager did not follow recipes, substituting ingredients and not tasting the food. The Administrator noted that this could result in residents not receiving a balanced diet.
The facility failed to maintain sanitary conditions in its kitchen by not labeling or properly closing food items in the freezers. Observations revealed that several opened bags of food, such as okra, waffles, corn, squash, and riblets, were not labeled with product or expiration dates and were exposed to air. The Dietary Manager and Administrator acknowledged the importance of proper labeling and storage to prevent serving expired foods to residents.
The facility failed to accurately complete MDS assessments for two residents receiving anticoagulant medications. One resident with a history of embolism and thrombosis was prescribed Eliquis, and another with venous thrombosis and embolism was prescribed apixaban. Despite receiving these medications, their MDS assessments did not reflect this, due to oversight by the MDS nurse. Interviews revealed a lack of backup for accuracy checks, leading to the oversight.
A facility failed to include the anticoagulant medication Eliquis in a resident's care plan, despite its prescription and administration for managing embolism and thrombosis. The omission was identified through interviews with staff, who acknowledged the lack of a backup system to verify care plan accuracy. The facility's policy mandates comprehensive care plans, which was not followed in this instance.
A facility failed to remove an expired insulin pen from a medication cart, which was used for a resident with severe cognitive impairment and diabetes. The insulin pen, opened 60 days past its expiration, was found during a cart review. Despite daily checks by nurses and monthly checks by a pharmacy consultant, the expired pen was overlooked, potentially affecting the medication's effectiveness.
The facility failed to follow the menu and recipes for a lunch meal, leading to deviations in the chicken wrap and potato salad served. The Dietary Manager did not adhere to the recipes due to missing ingredients and personal preferences, resulting in potential nutritional inadequacies. The Administrator expected the recipes to be followed and missing ingredients to be reported for purchase.
A resident with a history of sexual behaviors inappropriately touched another resident in a dining area, despite staff awareness and previous interventions. The incident was witnessed by two other residents who alerted staff, leading to immediate separation. The facility's failure to manage the resident's behaviors and protect others highlights a deficiency in ensuring resident safety.
Resident Council Food Grievances Not Promptly Addressed
Penalty
Summary
The facility failed to consider the views of the resident council and act promptly on grievances and recommendations related to resident care and life in the facility for 16 anonymous residents who attended a confidential meeting. Resident Council Meeting Minutes from 09/11/25, 10/09/25, and 11/13/25 documented repeated dietary concerns, including requests for fried and boiled eggs, wheat bread for diabetics, toast that was not too hard, less spicy chili, and fried eggs instead of scrambled eggs. The attached dietary forms also reflected ongoing concerns about food quality and specific menu items, including requests for real fried chicken, cottage cheese, and fried fish fillet. During the confidential interview, all 16 anonymous residents stated their food grievances were not addressed or resolved promptly. They reported the food was terrible, bland, cold, and repetitive, and said the food was discussed at every resident council meeting without improvement. The AD stated she normally facilitated resident council meetings and that food was a constant issue, while the Administrator stated he had only attended one meeting, a grievance form had been completed, and the issue was addressed. The Resident Council policy stated the Nutrition/Culinary Services Director/Designee receives council minutes and responds in writing to concerns identified and actions taken.
Meals Not Served Palatably or at Proper Temperature
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and served at a safe and appetizing temperature for 8 of 16 residents reviewed for food and nutrition services. Multiple residents reported that meals were too salty, bland, cold, dry, hard, or otherwise unappetizing, and several observations confirmed those concerns during meal service. Resident #15, who had diagnoses including major depressive disorder and anxiety and had intact cognition on MDS, stated that food was too salty depending on who cooked it, that gravy was not served, and that meat was dry. During a meal observation, she said the chicken dish had no flavor, the tortillas in the casserole were tough, the cornbread looked underbaked, the green beans were bland, the peaches tasted like canned peaches, and the iced tea was very watery. She also reported that scrambled eggs were dry and that she had been told she could only have fried eggs on a designated day, which she did not know. Resident #20, who had diagnoses including major depressive disorder, dysphagia, and anxiety disorder and had moderately impaired cognition, said the food was terrible and that pancakes were hard. During lunch observation, the cornbread appeared pale and undercooked. The resident also reported a piece of plastic in his peaches, and a small piece of plastic was observed on the table near his plate. Other residents similarly reported poor food quality: Resident #24 said the food did not taste good and was too salty; Resident #27 said the food did not taste good, was either too salty or not salty enough, and that pancakes were hard; Resident #37 said the food was cold and tasted like slop; Resident #38 said the eggs were cold and the food tasted bad; Resident #48 said the food was horrible and she would not eat it; and Resident #49 said he was served cold eggs and hard pancakes and that food was sometimes too salty. During a lunch meal observation with surveyors and the Dietician, the Shepherd's Pie was described by surveyors as bland, the honey dew melon was crunchy and hard, the biscuit was slightly dry and crumbly, and the peaches tasted like canned peaches. The Dietician stated that fruit was served as dessert almost every meal. Interviews with the Dietician, Dietary Manager, CNA, RN, DON, and Administrator reflected that complaints about bland food, seasoning, small portions, and unappetizing meals had been heard by staff, and the facility records included resident council and grievance concerns about food being too spicy or chicken being overfried and spicy. The facility policy stated that meals are to be served attractively and at the correct temperature and should meet individual food preferences.
Infection Control Lapses During Meal Service and Incontinent Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for 1 of 3 hallways, D Hall, and for 1 resident reviewed for infection control practices. During a meal service observation, an LVN passed lunch trays to multiple resident rooms on D Hall and did not sanitize her hands or perform hand hygiene between each tray delivery. She entered rooms, set up trays, and in some rooms moved items on bedside tables, blankets, and bed coverings before leaving, but did not clean her hands between residents. When interviewed, the LVN stated she normally sanitized her hands between rooms but did not have sanitizer in her pocket and forgot to use the hallway pumps. The facility also failed to ensure proper glove use and hand hygiene during incontinent care for a resident with chronic respiratory failure and morbid obesity. The resident’s record showed severe cognitive impairment, was always incontinent of bladder, and was usually dependent on staff for toileting hygiene. During observation, a CNA washed her hands, donned an isolation gown and gloves, and began incontinent care. She cleaned the resident from the front, rinsed and dried, then turned the resident to the back and continued cleaning, rinsing, and drying while using the same pair of gloves throughout the entire care episode. She adjusted the resident’s covers and removed her gloves only at the end, without changing gloves or performing hand hygiene during the care. In interviews, the CNA stated she should have changed her gloves and performed hand hygiene when moving from the front to the back and from dirty to clean, and before touching anything clean. The DON stated staff were expected to perform hand hygiene during meal tray passing and during incontinent care when moving from dirty to clean and from the front to the back, and to change gloves when soiled. The Administrator stated staff were expected to follow infection control policies and procedures, and the infection control preventionist was responsible for monitoring staff compliance.
Room Not Kept Clean or in Good Repair
Penalty
Summary
The facility failed to ensure Resident #40 had a safe, clean, and comfortable homelike environment. Resident #40 was an alert and oriented female admitted with a diagnosis of cancer of the tongue, and her admission MDS was still in progress. During observation, her bathroom toilet was running, the faucet sprayed water onto the surveyor’s badge when turned on, and the resident stated her shirt became wet every time she washed her hands. She also reported that the window had been opened and was filthy, and that her walls had missing paint. The surveyor observed a small area of missing paint and deep gouges in the sheetrock near the floor on the back wall beside her bed, warped and wavy blinds, a slightly raised window, and a thick layer of brown gritty substance and dark brown gritty clumps between the outside screen and window. Resident #40 stated she had reported the issues to staff but said no one had fixed them yet, and she said the condition of the room made her feel disappointed because things were not completed the way she did them at home. A CNA stated the resident had reported the running toilet and that she had instructed the resident to jiggle the handle. The unit manager stated she had not been aware of concerns with the room, toilet, or faucet, and the Director of Support Services stated no work orders had been received for the room. The Administrator stated the dirt buildup in the window was not something the facility monitored regularly and expected room-ready checklists and cleaning protocols to be followed. Maintenance logs for the month contained no entries for Resident #40’s room.
Unsecured Shower Room Contained Chemicals and Razors
Penalty
Summary
The facility failed to ensure the shower room on Hall C remained secured when not in use. During an observation, the shower room door was not locked, and the room contained a plastic cabinet approximately 6 feet tall with one of two doors missing. Inside the cabinet were two 6-ounce bottles of body wash labeled to keep out of reach of children and a package of disposable razors. No residents or staff were near the shower door at the time of the observation. During a later observation, the doorknob was set to lock, but the door was not latched and could be pushed open. The cabinet in the shower room still contained two 6-ounce bottles of body wash, a package of disposable razors, and a 32-ounce clear bottle with approximately 14 ounces of yellow liquid labeled disinfectant and labeled to keep out of reach of children. CNA C and CNA D stated the shower room was supposed to be locked when not in use and said residents could wander in and get hurt or injured with the chemical or razors. The Director of Support Services stated the shower door was not latching properly and had not been reported, and the DON stated broken doors were to be reported immediately and the cabinet was to be kept locked unless staff were giving a shower.
Missing Water Pitcher at Bedside
Penalty
Summary
The facility failed to ensure Resident #39 had a water pitcher at the bedside on 12/08/25, 12/09/25, and 12/10/25. Resident #39 was a male admitted with diagnoses including rhabdomyolysis, heart failure, and chronic kidney disease. The admission MDS dated 11/08/25 reflected clear speech and that he was understood by others and able to understand others, but also showed a BIMS score of 5, indicating severe cognitive impairment. He usually required supervision or touching assistance with eating, including liquids, and he received parenteral/IV feeding while a resident. The comprehensive care plan dated 11/13/25 identified that Resident #39 required regular/thin consistency liquids for nutritional support and was at risk for unplanned weight loss and nutritional complications. The plan also included interventions to assist with eating as indicated and to encourage fluid intake within dietary limits for his history of hypertension and constipation. His physician orders reflected a regular diet with regular/thin consistency liquids, revised on 12/10/25. During observation on 12/08/25, Resident #39 was sitting on the side of his bed and his bedside table did not have a water pitcher. He stated staff took his water pitcher out the prior week and never brought it back. On 12/09/25, he was observed lying in bed with no water pitcher at the bedside. On 12/10/25, CNA D stated she provided ice water at the beginning and end of her shift and would get a pitcher from dietary if needed, but was unsure whether Resident #39 had one. CNA F, who normally worked the hallway, stated she passed ice water at the beginning of her shift and as needed, and when the surveyor and CNA F entered Resident #39's room there was no water pitcher; CNA F then stated she would get him one. The Treatment Nurse stated CNAs should pass ice at the beginning and end of their shifts and that she was unaware Resident #39 did not have a water pitcher. The DON stated she expected all residents to have a water pitcher unless they could not have anything by mouth, and that nurses were responsible for monitoring to ensure pitchers were at the bedside. The facility policy stated staff would clean reusable water pitchers and glasses and, when supplies were available, return the water pitcher to the resident's room and fill it with ice water.
Failure to Document Narcotic Pain Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, administering, and reconciliation of drugs and biologicals for Resident #46. Resident #46 was a male resident admitted with osteoarthritis and pain, had a BIMS score of 11, and had an order for Acetaminophen-Codeine 300 mg-30 mg (Tylenol #3) every 6 hours as needed for pain. The care plan addressed pain management, including assessing pain, giving pain medications, checking effectiveness, and monitoring for side effects. Record review showed Tylenol #3 was administered on 12/02/25 at 4 PM, 12/04/25 at 8 PM, and 12/06/25 at 8 AM on the Controlled Drug Administration Record, but those doses were not signed out on the electronic MAR. During interviews, the DON stated narcotic medications were expected to be documented on both the electronic MAR and narcotic count sheet, and that monitoring for proper signing was not completed because she and the ADON were working the floor. LVN G stated she did not always sign out Resident #46's narcotic pain medication in both places because she became distracted and forgot. The Administrator stated staff were expected to sign out narcotic pain medications as they were given and that nursing management was responsible for monitoring reconciliation.
Failure to Honor Documented Food Allergies and Preferences
Penalty
Summary
The facility failed to ensure that Resident #19 received food that matched her documented allergies and preferences. Resident #19 had diagnoses including dementia, paranoid schizophrenia, and major depressive disorder, and her quarterly MDS indicated she was understood and had a BIMs score of 13, showing intact cognition. Her care plan identified her as at risk for an allergic reaction due to allergies to eggs and yeast, and her EMR listed egg and yeast allergies, although the order summary did not include food allergies. During interviews and observation, Resident #19 stated she could not eat eggs and said the kitchen kept sending her eggs. On observation, she was served breakfast with scrambled eggs mixed with sausage, and the meal ticket indicated egg and sausage casserole without noting an egg allergy. She said she was served eggs every morning and that she only ate the cereal on her tray. Staff interviews showed conflicting information about whether she was truly allergic to eggs or whether she simply did not want eggs. The dietary manager said the resident was not actually allergic but did not want to be served eggs, while CNA and nursing staff stated she had been served eggs and that she did not want them on her plate. The DON documented that the resident's representative verified she was not allergic to eggs or yeast, but the resident continued to have egg and yeast allergies listed in the EMR and care plan. The dietary manager stated the resident's dietary card had not been updated since admission two years earlier and that nurses were supposed to send dietary a paper listing allergies and preferences. Facility policy required food allergies to be documented and communicated, with meal tickets able to note allergies, and required foods to meet individual resident preferences. The Administrator stated staff were expected not to serve food a resident was allergic to or preferred not to have.
Failure to Complete Quarterly Smoking Assessment
Penalty
Summary
The facility failed to establish and follow smoking policies in accordance with applicable Federal, State, and local laws and regulations for smoking, smoking areas, and smoking safety, including consideration of nonsmoking residents. For one resident reviewed for smoking, the facility did not complete the required quarterly smoking assessment. The resident’s record showed a smoking safety screen completed once, which identified the resident as a safe smoker, and the care plan documented that the resident was a tobacco smoker at risk for injury and that safe smoking risk assessments were to be completed routinely. The facility’s Safe Smoking policy stated that residents who desire to smoke would be assessed using the safe smoking screen and that assessments would be conducted at admission and quarterly. The resident was a female with diagnoses including dementia, bipolar disorder, and seizures. Her comprehensive MDS indicated a BIMS score of 15 and that she used tobacco. The facility’s smoker list identified her as a smoker. During observation, she was seen outside smoking with a staff member present, and she was smoking without assistance. During interview, the DON stated that she and the management team were responsible for completing quarterly smoking assessments, that the electronic system was supposed to alert them when assessments were due, and that only one smoking assessment was found in the resident’s electronic record.
Incomplete Documentation of Incontinence Care Due to EMR Limitations
Penalty
Summary
The facility failed to maintain complete and accurate clinical records in accordance with accepted professional standards for two residents who required total care for toileting hygiene due to severe cognitive impairment and incontinence. Record reviews showed that both residents' care plans required routine rounding and incontinence care, but the CNA flow sheets for November 2025 did not accurately document each instance of incontinence care or checks. Documentation was incomplete, with no indication that incontinence care was provided as required, despite staff statements that care was given every two hours. Interviews with staff revealed that recent updates to the electronic medical record system had removed the option for CNAs to chart each episode of incontinence care or checks, limiting documentation to one or two times per shift. The DON confirmed that she was unaware of how long this documentation issue had persisted and acknowledged responsibility for ensuring complete and accurate medical records. The facility's policy allowed for electronic medical records in lieu of paper records, but the system's limitations led to incomplete documentation of care provided.
Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
A deficiency occurred when a resident, assessed as high risk for elopement due to diagnoses including dementia, hypertension, type 2 diabetes, anxiety, and depression, was left unsupervised on a secured memory care unit. The resident had a history of restlessness, attempts to leave the unit, and expressed a desire to go home, as documented in multiple nurse notes. The care plan and risk assessments identified the need for frequent checks and supervision, especially during high-risk times. On the day of the incident, the staff member assigned to supervise the secured unit left the area unattended. The charge nurse had instructed a CNA to relieve the current staff member for a lunch break, but the CNA failed to go to the unit as directed and was observed elsewhere in the facility. During this period, the resident eloped from the secured unit, using a chair and trash can to climb over the courtyard fence. The resident was later found at his previous home address, approximately one mile from the facility, and was returned without injury. Interviews with staff confirmed that the CNA assigned to the unit was not present at the time of the elopement, and the absence of supervision directly contributed to the resident's ability to leave the facility. Documentation and staff statements indicated that the resident's risk for elopement was well known, and the failure to provide adequate supervision resulted in the resident's unsupervised departure from the secured unit.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect multiple residents from physical abuse by other residents, as evidenced by several documented incidents. One resident with Huntington's disease and severe cognitive impairment was slapped on the neck and had her hair pulled by another resident with alcohol-induced dementia and psychosis. This incident was witnessed by an LVN, who observed the aggressor hitting the resident in the face and pulling her hair while both were in wheelchairs in the hallway. The same resident was later punched in the arm by the same aggressor during another incident, which was also witnessed by staff. In both cases, the residents were separated, and the aggressor was returned to his room, but the incidents still occurred despite staff awareness of a history of resident-to-resident incidents between these individuals. Another incident involved a resident with vascular dementia pushing a resident with Alzheimer's disease and PTSD, causing the latter to fall in the dining room. This event was witnessed by a contracted lab technician, who saw the push and subsequent fall. The resident who fell was upset but not injured, and both residents were separated following the incident. The aggressor was placed on 1:1 monitoring, but the altercation had already taken place, indicating a failure to prevent physical abuse between residents. The residents involved in these incidents had significant cognitive and behavioral health diagnoses, including Huntington's disease, bipolar disorder, schizoaffective disorder, alcohol-induced dementia, psychosis, vascular dementia, Alzheimer's disease, and PTSD. Care plans for these residents included interventions such as monitoring for behaviors, redirection, and 1:1 interaction as needed. Despite these interventions being documented, the facility did not prevent the physical altercations, and staff were aware of the potential for such incidents due to the residents' histories and diagnoses.
Failure to Thoroughly Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to provide evidence that all allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated for four out of six residents reviewed. Specifically, there were three separate incidents involving resident-to-resident altercations that were not fully investigated according to facility policy and regulatory requirements. In two incidents, one resident was slapped on the neck and later punched on the arm by another resident, and in a third incident, a resident was pushed by another, resulting in a fall. In each case, the facility's investigation did not include documentation that other residents were interviewed to ensure their safety and wellbeing following the allegations. The residents involved had significant cognitive and physical impairments, including diagnoses such as Huntington's disease, bipolar disorder, schizoaffective disorder, dementia, and other mental health conditions. Assessments indicated that these residents had severely to moderately impaired cognition and required varying levels of assistance with daily activities. Despite these vulnerabilities, the facility did not complete or document 'safe surveys' or interviews with other residents who may have been affected or witnessed the incidents, as required by facility policy. Interviews with staff, including the DON, social worker, and administrator, revealed a lack of clarity and follow-through regarding responsibility for conducting and documenting safe surveys after abuse allegations. The DON and administrator acknowledged that the facility's policy required such actions, but stated that these were not completed or documented, particularly when the social worker was unavailable. The facility's own policy outlined the need for comprehensive investigations, including interviews with other residents, but this was not consistently followed or recorded in the cases reviewed.
Failure to Update Care Plans After Resident-to-Resident Aggression
Penalty
Summary
The facility failed to review and revise the comprehensive care plans for two residents after significant incidents of resident-to-resident aggression. For one resident with Huntington's disease, bipolar disorder, major depressive disorder, schizoaffective disorder, and anxiety disorder, the care plan was not updated to reflect incidents where she was the recipient of aggressive behavior from another resident. These incidents included being hit and having her hair pulled, as well as being punched in the arm. Despite assessments and monitoring following these events, the care plan did not document these changes or add new interventions related to the aggression she experienced. Another resident, diagnosed with alcohol-induced dementia, psychosis disorder, COPD, diabetes mellitus, anxiety disorder, and depressive disorder, was involved as the aggressor in the same incidents. His care plan was also not updated to reflect his involvement in the aggressive behaviors, nor were new interventions or strategies documented to address these behaviors. Both residents had severely impaired cognition and required varying levels of assistance with daily activities and mobility, as documented in their assessments. Interviews with staff revealed that incidents and allegations were discussed in morning meetings, and the MDS Coordinator was responsible for updating care plans. However, the care plans for both residents were not revised after the incidents, and the DON acknowledged that she did not verify whether the updates had been made. The facility's policy required care plans to be reviewed and revised after a change in status, but this process was not followed, resulting in care plans that did not reflect the residents' current needs after the incidents.
Failure to Timely Report Alleged Physical Abuse Incident
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported to the State Survey Agency within the required timeframe. Specifically, an incident occurred in which one resident, who had a history of Huntington's disease and severely impaired cognition, was punched in the arm by another resident with a diagnosis of alcohol-induced dementia and psychosis disorder. The incident was witnessed by an LVN, who immediately separated the residents and reported the event to the DON, ADON, and the administrator. Resident assessments following the incident revealed no injuries or pain, and the event was documented in the facility's records. Despite the facility's policy defining physical abuse as including hitting and requiring immediate reporting of such incidents, the event was not reported to the state agency within the mandated two-hour window. The DON and administrator were both notified of the incident and conducted an internal investigation. During this process, the resident who was punched denied being hit and described the event as the other resident moving her arm out of his face. Based on this information and after consultation with a corporate nurse, the decision was made not to report the incident as abuse to the state agency. A review of the Texas Unified Licensure Information Portal confirmed that no self-reported incidents regarding allegations of abuse were submitted for the resident involved. Both the DON and administrator acknowledged during interviews that, according to facility policy, the incident should have been reported as an alleged physical abuse event to the state agency within two hours, regardless of the internal investigation's findings. The failure to report the incident as required constituted a deficiency in the facility's abuse reporting procedures.
Failure to Maintain Accurate Controlled Drug Inventory and Shift Counts
Penalty
Summary
The facility failed to establish and maintain an adequate system for the receipt and disposition of controlled drugs, specifically hydrocodone/acetaminophen prescribed to a female resident with a hip fracture and severely impaired cognition. The resident was admitted with an order for hydrocodone 5 mg/acetaminophen 325 mg, and her medication was brought in by her representative. Upon arrival, the medication was counted by two nurses and a count sheet was created, but subsequent handling of the medication was inconsistent and not in accordance with facility policy. During the period under review, nursing staff did not consistently count the narcotic medications during shift changes, and not all narcotics had an associated Inventory Sheet. On one occasion, the hydrocodone/acetaminophen was not counted and lacked an Inventory Sheet. Discrepancies in pill counts were identified, with counts varying between staff and the resident's representative, and a significant number of pills were found to be missing. The MAR indicated fewer pills had been administered than the number missing from the bottle, and the required narcotic sheet for the bottle was missing at the time of the investigation. Interviews with staff revealed that nurses did not always count narcotics together at shift change, and one nurse accepted the narcotic keys without performing the required count. The facility's policy requires controlled drugs to be counted at every shift change by both oncoming and off-going staff, with counts recorded on the Narcotic Records. These procedures were not followed, resulting in an inability to accurately reconcile the controlled drug inventory and maintain proper records.
Failure to Provide Palatable and Nutritious Meals
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, attractive, and at a safe and appetizing temperature. During initial rounds, residents complained about the food tasting bad and being inedible at times. On a specific day, a test tray containing a chicken ranch wrap, potato salad, and pear crisp was observed. The chicken wrap was not properly wrapped and resembled a taco, with soggy breaded meat that did not taste like chicken. The potato salad had an overpowering garlic flavor, which was not part of the original recipe. The Dietary Manager (DM) admitted to not tasting the food during preparation and not following the recipes, citing personal dietary preferences. He used breaded chicken patties instead of the specified chicken due to a delivery issue and substituted canned tomatoes for fresh ones. Additionally, he altered the potato salad recipe by omitting hard-boiled eggs and pickle relish and adding garlic. Residents expressed dissatisfaction with the meal, stating that the chicken wrap and potato salad were unpalatable. The Administrator acknowledged that not following recipes could lead to residents not receiving a nutritionally balanced diet and emphasized the importance of adhering to approved menus and recipes.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in its kitchen, specifically in the storage of food items in the freezers. During an observation, it was noted that several food items in Freezer #1 and Freezer #2 were not labeled with product or expiration dates. These items included opened bags of okra, waffles, corn, squash, and riblets. Additionally, some of these items were not properly closed, leaving them exposed to air, which could lead to freezer burn and potential contamination. The Dietary Manager acknowledged that all opened foods should be labeled with the date opened and properly closed to prevent such issues. The facility's policy on food storage, as well as the 2022 Food Code, requires that frozen foods be stored in moisture-proof wrap or containers that are labeled and dated. The Dietary Manager confirmed that the lack of labeling and proper storage could result in expired foods being served to residents. The Administrator, who supervises the Dietary Manager, also stated that he expected all foods in the kitchen to be stored properly, including labeling and dating, to prevent the risk of serving expired foods to residents.
Inaccurate MDS Assessments for Anticoagulant Use
Penalty
Summary
The facility failed to ensure accurate assessments for two residents regarding their anticoagulant medication use. Resident #5, a female with a history of embolism and thrombosis, was prescribed Eliquis for venous thrombosis. Despite receiving this medication as per her physician's orders and medication administration records, her most recent MDS assessment did not reflect her anticoagulant use. Additionally, her care plans did not indicate the receipt of this medication, although she confirmed during an observation that she was on an anticoagulant. Similarly, Resident #54, a female with a diagnosis of venous thrombosis and embolism, was prescribed apixaban for heart failure. Her medication administration records confirmed the administration of this medication, yet her MDS assessment failed to capture this information. Her care plan did acknowledge the anticoagulant use, but during an observation, she was unable to specify the medication she was receiving. Interviews with the MDS nurse, Regional Reimbursement Director, DON, and Administrator revealed that the MDS assessments were not accurately coded for anticoagulant medication due to oversight. The MDS nurse was responsible for all MDSs and acknowledged the error, noting a lack of backup for accuracy checks. The Regional Reimbursement Director and DON were unaware of the oversight, and the Administrator emphasized the need for 100% compliance in documentation.
Failure to Include Anticoagulant in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, specifically regarding the administration of the anticoagulant medication, Eliquis. The resident, a cognitively intact female, was admitted with a history of embolism and thrombosis and was prescribed Eliquis to manage her condition. Despite receiving the medication as per the physician's orders, the resident's care plan did not reflect the administration of this anticoagulant, nor did the most recent MDS assessment indicate its use. Interviews with facility staff, including the MDS Nurse, Regional Reimbursement Director, DON, and Administrator, revealed that the oversight was due to a lack of double-checking for accuracy in care plans. The MDS Nurse, responsible for care plans, acknowledged the omission and stated that there was no backup system in place to verify the accuracy of care plans. The facility's policy requires the interdisciplinary team to develop a comprehensive care plan for each resident, but this was not adhered to in this case, leading to the deficiency.
Expired Insulin Pen Not Removed from Medication Cart
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not removing an expired insulin pen from a medication cart, which was used for a resident with end-stage renal disease and type 2 diabetes mellitus. The insulin pen, Insulin Glargine yfgn, was opened on 08/03/24 and had expired 60 days prior to the survey, yet it remained in use. This oversight was identified during a review of the medication cart on Hall B and the right side of Hall C, where the pen was found with a label indicating the resident's name and the open date. The resident involved was a male with severe cognitive impairment, as indicated by a BIMS score of 3, and had been receiving insulin injections daily. The resident's care plan required insulin administration as prescribed and monitoring for side effects and effectiveness. Despite these requirements, the expired insulin pen was not removed from the medication cart, potentially compromising the therapeutic effects of the medication. Interviews with the LVN, DON, ADON, and Administrator revealed that the nurses were responsible for checking their medication carts daily for expired medications. The pharmacy consultant conducted monthly checks, and the DON and ADON performed surprise checks quarterly. However, the expired insulin pen was overlooked, and the staff acknowledged that the insulin might not have been as effective due to its prolonged use beyond the recommended time frame.
Failure to Follow Menu and Recipes for Nutritional Adequacy
Penalty
Summary
The facility failed to ensure that the menu was followed for one of the three meals reviewed, specifically the lunch meal on October 1, 2024. During an observation and interview, it was noted that the chicken ranch wrap served did not adhere to the recipe. The wrap was not properly wrapped and resembled a taco, with soggy breaded meat that did not taste like chicken, and canned tomatoes instead of fresh. The potato salad also deviated from the recipe, having a strong garlic flavor and missing key ingredients like hard-boiled eggs and pickle relish. The Dietary Manager (DM) admitted to not following the recipes, citing a lack of ingredients due to a delivery issue and personal dietary preferences as reasons for not tasting the food. The DM acknowledged that not following the recipes could result in residents not receiving dietician-approved meals, potentially decreasing the nutritional value and altering the taste of the food. The facility's Administrator stated that the expectation was for menus and recipes to be followed, and any missing ingredients should have been reported so they could be purchased. The facility's Food Preparation policy emphasizes the importance of using standardized recipes to conserve nutritive value, flavor, and appearance, which was not adhered to in this instance.
Inadequate Protection from Abuse in LTC Facility
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse, specifically inappropriate sexual touching, involving two residents. Resident #1, a female with dementia and other cognitive impairments, was inappropriately touched by Resident #2, a male with a history of sexual behaviors and cognitive impairments, in the dining area. This incident was witnessed by two other residents who alerted the staff, leading to the immediate separation of the involved residents. Despite Resident #2's denial of the incident, the observations of the witnesses confirmed the inappropriate behavior. Resident #2 had a documented history of inappropriate sexual behaviors towards staff and other residents, with multiple incidents recorded over several months. These behaviors included inappropriate comments, gestures, and touching, which were often redirected by staff. Despite various interventions, including medication adjustments and psychiatric evaluations, Resident #2's behaviors persisted. The facility's records indicate that Resident #2 had been transferred to a behavioral hospital multiple times due to these ongoing issues. The facility's failure to adequately manage Resident #2's behaviors and protect Resident #1 from abuse highlights a significant deficiency in ensuring resident safety. The incident involving Resident #1 and Resident #2 was reported to the state agency, and the facility's records show that staff were aware of Resident #2's behaviors and had been instructed to monitor him closely. However, the measures in place were insufficient to prevent the incident from occurring, resulting in a breach of the residents' right to be free from abuse.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 131 citations issued within 25 miles in the last 12 months — including the 11 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Silsbee
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Silsbee Oaks Health Care Llp | 1.3 mi | ★★★★★ | 9 | 0 |
| Mill Creek | 2.4 mi | ★★★★★ | 7 | 0 |
| Village Creek Rehabilitation And Nursing Center | 6.9 mi | ★★★★★ | 16 | 3 |
| Paradigm At Kountze | 10.1 mi | ★★★★★ | 5 | 0 |
| Jefferson Nursing And Rehabilitation Center | 16.3 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.