Paradigm at the Creek

In the surveyor’s words

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

• Immediate jeopardy, patternF656Aug 4, 2025

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

• Immediate jeopardy, isolatedF689Jul 25, 2026

  Based on observation, interview, and record review, the facility failed to ensure that residents received sufficient supervision to prevent avoidable accidents for 1 (CR#1) out of 5 residents reviewed for accidents. The facility failed to provide sufficient supervision to CR#1 on 7/15/2026 - 7/16/2026 when he eloped at an unknown time through his room window ,from the facility secure unit. CR#1 was not supervised for behaviors of wandering per physician order resulting in elopement.CR #1 was not identified to be missing from the facility until 7/16/2026 at 7:00 am. The failure could place residents at risk for injury, hospitalization, or death. An Immediate Jeopardy (IJ) was identified on 7/23/2026 at 5:59 pm. […]

• Immediate jeopardy, isolatedF600Sep 30, 2024

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

• Immediate jeopardy, isolatedF725Sep 30, 2024

  Based on observation, interview, and record review the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility's assessment tool for 2 of 19 residents (Resident #2 and Resident #3)reviewed for sufficient staff. […]

• Immediate jeopardy, isolatedF678May 28, 2024

  Based on observation, interview, and record review, the facility failed to ensure personnel provided basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel for 1 of 19 residents (CR #1) reviewed for CPR. 1. Laundry Aide D failed to call a code blue or express CR #1 experienced a medical emergency when she requested assistance in the locked memory care unit after CR #1 was noted to be unresponsive on [DATE]. This led to a delay of at least three minutes before nursing staff arrived to assess CR #1, who died shortly after arrival to the ER. 2. […]