Paradigm at the Oak

In the surveyor’s words

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

• Immediate jeopardy, patternF689Jan 17, 2025

  Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents and supervision, in that: The facility failed to ensure Resident #1 received adequate supervision to prevent him from exiting the facility undetected on 12/09/24 and 12/31/24. The non-compliance was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 12/09/24 and ended on 01/01/25. The facility corrected the non-compliance before the investigation began on 01/08/25. […]

• Immediate jeopardy, isolatedF600Feb 20, 2026

  Based on interview and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for one of six residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 had the right to be free from abuse when on 02/07/2026 at approximately 10:00 AM LVN A told Resident #1 to sit right or he was going to fall back, and he would get blood all over the floor and LVN A would have to pick it up. LVN A pushed Resident #1's head forward in the dining room which humiliated him, and LVN A continued to be Resident #1's nurse after the incident and a the day after the incident. The noncompliance was identified as Past Noncompliance. […]

• Immediate jeopardy, isolatedF607Feb 20, 2026

  Based on interview and record review, the facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 (Resident #1) of 6 residents reviewed for abuse and neglect. The facility failed to remove LVN A from duty and she continued to work with Resident #1 after witnessed abuse was reported to the administrator. The noncompliance was identified as Past Noncompliance. The Immediate Jeopardy (IJ) began on 02/07/2026 and ended on 02/11/2026. The facility had corrected the noncompliance before the survey began. […]

• Immediate jeopardy, isolatedF610Feb 20, 2026

  Based on interviews and record review, the facility failed to have evidence that all allegations of abuse, neglect, or mistreatment were thoroughly investigated and documented for 1 of 6 residents (Resident #1) reviewed for abuse and neglect. The facility failed to have evidence that a thorough investigation was conducted following the allegation that on 02/07/2026 LVN A spoke tapped Resident #1 in the back of the head. The noncompliance was identified as Past Noncompliance. The Immediate Jeopardy (IJ) began on 02/07/2026 and ended on 02/11/2026. The facility had corrected the noncompliance before the survey began. […]

• Immediate jeopardy, isolatedF600Nov 7, 2024

  Based on interview and record review, the facility failed to protect Resident #1's right to be free of sexual abuse by Resident #2. The facility failed to keep Resident #1 from being sexual assaulted by Resident #2 on 11/02/24. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 11/05/24 at 3:47 PM and an IJ template was given. While the IJ was removed on 11/07/24 at 3:21 PM, the facility remained out of compliance at a level 2 of no actual harm at a scope of isolated that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could place residents at risk of abuse, injury, and psychosocial harm. […]